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  1. ----------------------- TeleReg Registration ------------------------
  2.  
  3. Name
  4. ----
  5.  
  6. Surname___________________________ Given Name________________________
  7.  
  8.  
  9. Address
  10. -------
  11.  
  12. Street Address_______________________________________________________
  13.  
  14. City______________________________ Prov./State_______________________
  15.  
  16. Country___________________________ Postal/ZipCode____________________
  17.  
  18. Internet Address__________________ FIDONet Address___________________
  19.  
  20. Other E-mail Addresses (please specify)______________________________
  21.  
  22. _____________________________________________________________________
  23.  
  24.  
  25. Bulletin Board System you run
  26. -----------------------------
  27.  
  28. BBS Name__________________________ Phone Number______________________
  29.  
  30. Number of lines___________________ Baud Rate(s)______________________
  31.  
  32. Computers Supported__________________________________________________
  33.  
  34. BBS Software_________________________________________________________
  35.  
  36. Physical Address, if different from above____________________________
  37.  
  38. _____________________________________________________________________
  39.  
  40. FIDO Address, if different from above________________________________
  41.  
  42.  
  43. Payment
  44. -------
  45.  
  46. A registered (unlimited records) version of TeleReg is $29US.
  47.  
  48. Method of payment:
  49. [ ] Money order
  50. [ ] Personal cheque, please allow 3-4 weeks for clearance.
  51.  
  52. ---------------------------------------------------------------------
  53.