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  1. Registration form for HTML Map Designer Pro
  2.  
  3.  
  4. Program No.: 141273
  5.  
  6. Last name: __________________________________________________
  7.  
  8. First name: _________________________________________________
  9.  
  10. Company: ____________________________________________________
  11.  
  12. Street and #: _______________________________________________
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  14. City, State, postal code: ___________________________________
  15.  
  16. Country: ____________________________________________________
  17.  
  18. Phone: ______________________________________________________
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  20. Fax: ________________________________________________________
  21.  
  22. E-Mail: _____________________________________________________
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  24.  
  25. How would like to receive the registration key/full version?
  26.  
  27. e-mail - fax - postal mail
  28.  
  29.  
  30. How would you like to pay the registration fee:
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  32. credit card - wire transfer - EuroCheque - cash
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  34.  
  35. Credit card information (if applicable)
  36.  
  37. Credit card: Visa - Eurocard/Mastercard - American Express - Diners Club
  38.  
  39. Card holder: ___________________________________________
  40.  
  41. Card No.: ______________________________________________
  42.  
  43. Date of Expiration : ___________________________________
  44.  
  45.  
  46. Date / Signature _______________________________________
  47.  
  48.  
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