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Text File  |  1992-10-17  |  2KB  |  55 lines
  1.  
  2.                  WinMod Version 1.0 Registration
  3.  
  4.   Please fill out this form, then (e)mail/fax it to
  5.     
  6.         CARECOM(R)
  7.         Norbert Unterberg
  8.         Gustav-Vorsteher-Strasse 14
  9.         D-5802 Wetter/Ruhr 1
  10.         Germany
  11.  
  12.         CompuServe: 100112,2740
  13.         Fax: ++49-2335-3821
  14.  
  15.   
  16.   Name: ___________________________________________________________________
  17.  
  18.   Title: __________________________________________________________________
  19.  
  20.   Company: ________________________________________________________________
  21.  
  22.   Address: ________________________________________________________________
  23.  
  24.            ________________________________________________________________
  25.  
  26.   City: _____________________________________   State: ________  Zip:______
  27.  
  28.   Country: ___________________________________________
  29.  
  30.   Telephone: _________________________________________
  31.  
  32.   E-mail: ____________________________________________
  33.  
  34.  
  35.  
  36.   Comments and Suggestions: _______________________________________________
  37.  
  38.   _________________________________________________________________________
  39.  
  40.   _________________________________________________________________________
  41.  
  42.  
  43.  
  44.   Please charge my credit card  [__] Eurocard   [__] Mastercard   [__] Visa
  45.  
  46.   Card Number: _______________________________  Expiration date: __________
  47.  
  48.   Cardholder: ________________________________  Amount (US-$): ____________
  49.                (The registration fee is
  50.                 US-$15 per license)
  51.  
  52.   Date: _______________  Signature: _______________________________________
  53.  
  54.   Thanks for your support!
  55.