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Text File  |  1995-01-08  |  1KB  |  44 lines
  1. Send to:
  2.  
  3. PD Profi Zoettlein GmbH        Phone: +49-8432-1296
  4. Schulstr. 13            Fax:   +49-8432-8674
  5. 86666 Burgheim            CIS:   100326,53
  6. Germany
  7.  
  8.  
  9.  
  10. Name:_______________________________________________________________
  11.  
  12. Address:____________________________________________________________
  13.  
  14. City:___________________________________ State:______ ZIP:__________
  15.  
  16. Country:____________________________________________________________
  17.  
  18. Phone:_____________________________ Fax:____________________________
  19.  
  20. EMail:_____________________________
  21.  
  22.  
  23. YES! I would like to purchase my personal registration number
  24. for Dave Dude 95, Release 2:
  25.  
  26. Registration# for Dave Dude 95, Release 2................._________
  27.     (before March 31st 1995 DM 29,- after that DM 39,-)
  28.  
  29. Shipping and handling (worldwide).........................  DM 10,-
  30.     
  31.                             Total:_________
  32. I pay by  [ ] eurocheque(included)  or
  33.  
  34. [ ] VISA  or  [ ] MasterCard  or  [ ] AmEx
  35.  
  36. Card#(16 digits):__ __ __ __  __ __ __ __  __ __ __ __  __ __ __ __ 
  37.  
  38. Expiration Date: __ __ / __ __ Cardholders name: __________________
  39.  
  40. Cardholders Signature: ____________________________________________
  41.  
  42.  
  43.  
  44. Date:__________________________ Signature:_________________________