        
                                   BMT Micro
                           FastLst Registration Form
        
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                   * DO NOT SEND this form to the author ! *
                   *****************************************
        
        See Register.Doc for instructions, please PRINT:  Date: __/__/__
        
        Name: __________________________________________________________
        
        Company: _______________________________________________________
        
        Address: _______________________________________________________
        
        ________________________________________________________________
        
        City: ______________________   State/Province: _________________
        
        Country: ___________________________ Postal Code: ______________
        
        Phone: _________________________________________________________
        
        Fax: ___________________________________________________________
        
        
                          REGISTRATION INFORMATION
        
        Reg.: __________________________________________________________
        
        e-mail to: _____________________________________________________
        
        Netmail to: ____________________________________________________
        
        Crash to: ______________________________________________________
        
        
        Product: FastLst (by Alberto Pasquale)         Price:  US$ 25.00
        
        North Carolina residents, please add 6% sales tax:    +US$ __.__
        
                                                       Total:  US$ __.__
        
        For credit card payment only:
        
        Circle one: VISA / Master / Discover / AMEX / Diner's Club
        
        Credit card number     : _______________________________________
        
        Expiration date        : ___/___
        
        Authorization signature: _______________________________________
        
