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  1. Send this form to :
  2.  
  3. Dancom Inc.
  4. PO Box 277
  5. CH-1110 Morges
  6. Switzerland
  7.  
  8.  
  9. SecureInit™ registration form
  10. -----------------------------
  11.  
  12. Company: __________________________________________________________
  13.  
  14. First Name: _______________________________________________________
  15.  
  16. Last Name: ________________________________________________________
  17.  
  18. Business Phone #: (____)____-______ Home Phone #: (____)____-______
  19.  
  20. Street Address: ___________________________________________________
  21.  
  22. City: _______________________ State: ___________ Zip code: ________
  23.  
  24. CompuServe Account #: _______,___ Delphi account name: ____________
  25.  
  26. ( ) I like to pay by check (I Add 5 $ for charges and make it payable
  27. to Dancom Inc. / Morges / Switzerland)
  28.  
  29.  
  30. CREDIT CARD CHARGE AUTHORISATION
  31. -------------------------------
  32. Card type:   American Express ( )   Visa ( )   MasterCard ( )
  33. Card holder name (completely as printed on card) :
  34.  
  35. ___________________________________________________________________
  36.  
  37. Card Number _____________________________________ Exp. date ___/___
  38.  
  39. Credit card authorizing signature : _________________ Date:________
  40.  
  41. Version of SecureInit™ you are currently running: _________________
  42.  
  43. Computers owned (include details of peripherals):
  44. ___________________________________________________________________
  45. ___________________________________________________________________
  46. ___________________________________________________________________
  47. ___________________________________________________________________
  48. ___________________________________________________________________
  49. ___________________________________________________________________
  50. ___________________________________________________________________
  51.