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Text File  |  1996-07-18  |  2KB  |  55 lines
  1.         
  2.                                    BMT Micro
  3.                            FastLst Registration Form
  4.         
  5.                    *****************************************
  6.                    * DO NOT SEND this form to the author ! *
  7.                    *****************************************
  8.         
  9.         See Register.Doc for instructions, please PRINT:  Date: __/__/__
  10.         
  11.         Name: __________________________________________________________
  12.         
  13.         Company: _______________________________________________________
  14.         
  15.         Address: _______________________________________________________
  16.         
  17.         ________________________________________________________________
  18.         
  19.         City: ______________________   State/Province: _________________
  20.         
  21.         Country: ___________________________ Postal Code: ______________
  22.         
  23.         Phone: _________________________________________________________
  24.         
  25.         Fax: ___________________________________________________________
  26.         
  27.         
  28.                           REGISTRATION INFORMATION
  29.         
  30.         Reg.: __________________________________________________________
  31.         
  32.         e-mail to: _____________________________________________________
  33.         
  34.         Netmail to: ____________________________________________________
  35.         
  36.         Crash to: ______________________________________________________
  37.         
  38.         
  39.         Product: FastLst (by Alberto Pasquale)         Price:  US$ 25.00
  40.         
  41.         North Carolina residents, please add 6% sales tax:    +US$ __.__
  42.         
  43.                                                        Total:  US$ __.__
  44.         
  45.         For credit card payment only:
  46.         
  47.         Circle one: VISA / Master / Discover / AMEX / Diner's Club
  48.         
  49.         Credit card number     : _______________________________________
  50.         
  51.         Expiration date        : ___/___
  52.         
  53.         Authorization signature: _______________________________________
  54.         
  55.