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Text File  |  1995-08-07  |  1.5 KB  |  48 lines
  1.                        ==============================
  2.                        ASSIMILATION REGISTRATION FORM
  3.                        ==============================
  4.  
  5.                YES, I'd like to receive registered Assimilation!
  6.  
  7.                   Return completed form via mail, or e-mail!
  8.  
  9.  
  10.             NAME:_____________________________________________________
  11.  
  12.          ADDRESS:_____________________________________________________
  13.  
  14.                  _____________________________________________________
  15.  
  16.             CITY:________________________ STATE/PROV:_________________
  17.  
  18.         ZIP CODE:____________________ PHONE/FAX:______________________
  19.  
  20.                                         COUNTRY:_______________
  21.  
  22.                                       Canadian orders: $16.00 per copy
  23.                                           U.S. orders: $13.00 per copy
  24.  
  25. ** Shipping & Handling is include in price!
  26.  
  27.                       Canadian ORDERS:  ----- copies @ $16.00 ea : -------
  28.  
  29.                           U.S. ORDERS:  _____ copies @ $13.00 ea : _______
  30.  
  31.                                                 >> TOTAL PAYMENT : _______
  32.  
  33. PAYMENT TYPE: ( ) Check  ( ) Money Order
  34.  
  35. ** Do not send cash in the mail!
  36.  
  37.           Make orders payable to Perry Robertson
  38.  
  39.            ALL ORDERS GO TO:
  40.             Perry Robertson
  41.             156 Chartwell Drive, Apt. 103
  42.             Sault Ste. Marie, ON, Canada
  43.             P6A 6A2
  44.  
  45.    Or phone:  (705) 946-5126 between 9:00am - 5:00pm Monday - Friday
  46.  
  47.    E-mail:  perry.robertson@csrnet-bbs.com
  48.