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  1. ShareIt! Registration form for Ultimate Paint
  2.  
  3. Program No.: 105450
  4.  
  5. Last name: ___________________________________
  6.  
  7. First name: ____________________________________
  8.  
  9. Company: ____________________________________
  10.  
  11. Street and #: ______________________________________
  12.  
  13. City, State, postal code: _____________________________
  14.  
  15. Country: _______________________________________
  16.  
  17. Phone: _____________________________________
  18.  
  19. Fax: ________________________________________
  20.  
  21. E-Mail: ______________________________________
  22.  
  23.  
  24. How would you like to pay the registration fee:
  25.  
  26. credit card - wire transfer - EuroCheque - cash
  27.  
  28.  
  29. Credit card information (if applicable)
  30.  
  31. Credit card: Visa - Eurocard/Mastercard - American Express - Diners Club
  32.  
  33. Card holder: ________________________________
  34.  
  35. Card No.: ___________________________________
  36.  
  37. Date of Expiration : ________________________________
  38.  
  39.  
  40.  
  41. Date / Signature ___________________________
  42.