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Text File  |  1995-05-05  |  2KB  |  50 lines
  1.                       BAD TOYS  REGISTRATION FORM
  2.                 ----------------------------------------
  3.  // This information is REQUIRED in order to process your registration //
  4.  
  5.                                             Date (dd/mm/yy)  ___/___/___
  6.  
  7.           Name: ________________________________________________________
  8.  
  9.        Address: ________________________________________________________
  10.  
  11.           City: ________________________________________________________
  12.  
  13. State/Province: ________________________________________________________
  14.  
  15.    Zip/Country: ________________________________________________________
  16.  
  17.       Payment
  18.       -------
  19.  
  20.   [ ] Amount paid by cheque (takes up to 10 days to clear)
  21.  
  22.   [ ] Money Order (please use mailing address shown below)
  23.  
  24.   [ ] Transfer to our bank account (please use bank info shown below)
  25.  
  26.   [ ] Credit Card   (only EuroCard/MasterCard)
  27.  
  28.       Card Number : ________ ________ ________ ________
  29.  
  30.       Expires     : ___/___
  31.  
  32.       Exact name on card (print) : ________________________________
  33.  
  34.             Signature(REQUIERED) : ________________________________
  35.  
  36.  
  37.   SUBTOTAL                                       $21.00
  38.   Shipping                                       $04.00
  39.                                                -----------
  40.   TOTAL AMOUNT                                   $25.00
  41.  
  42.   Signature(REQUIERED) : ________________________________
  43.  
  44.   Our mailing address:                Our bank Account:
  45.   --------------------                -----------------
  46.   Valach Pavel                        Ceskoslovenska Obchodni Banka A.S.
  47.   Varsavska 238                       pobocka Pardubice
  48.   53009 Pardubice                     Masarykovo nam. 1458
  49.   Czech Republic                      account number 20541010
  50.