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                                   BMT Micro
                           FastLst Registration Form

                   *****************************************
                   * DO NOT SEND this form to the author ! *
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      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$  1.50

                                                       Total:  US$ __.__

      For credit card payment only:

      Circle one: VISA / Master / Discover / AMEX / Diner's Club

      Credit card number     : _________________________________________

      Expiration date        : ___/___

      Authorization signature: _________________________________________

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