home *** CD-ROM | disk | FTP | other *** search
/ 200 Game / 200GAME2.iso / Super Puzzle / 15-Pack / order.frm < prev    next >
Encoding:
Text File  |  2000-04-10  |  1.3 KB  |  50 lines
  1. Registration form for 15-Pack
  2. -----------------------------
  3.  
  4. Program No.: 106546
  5.  
  6. Last name: _______________________________________________
  7.  
  8. First name: ______________________________________________
  9.  
  10. Company: _________________________________________________
  11.  
  12. Street and #: ____________________________________________
  13.  
  14. City, State, postal code: ________________________________
  15.  
  16. Country: _________________________________________________
  17.  
  18. Phone: ___________________________________________________
  19.  
  20. Fax: _____________________________________________________
  21.  
  22. E-Mail: __________________________________________________
  23.  
  24. *** Please do not forget to include your e-mail address. ***
  25. *** We will use e-mail to communicate with you. ***
  26.  
  27.  
  28. How would like to receive the registration key/full version?
  29.  
  30.  __ e-mail   __ fax   __ postal mail
  31.  
  32.  
  33. How would you like to pay the registration fee:
  34.  
  35.  __ credit card   __ wire transfer   __ EuroCheque   __ cash
  36.  
  37.  
  38. Credit card information (if applicable)
  39.  
  40. Credit card:  __ Visa   __ Eurocard/Mastercard
  41.           __ American Express   __ Diners Club
  42.  
  43. Card holder: ________________________________
  44.  
  45. Card No.: ___________________________________ Expiration Date: ________
  46.  
  47.  
  48.  
  49. Date / Signature: ___________________________
  50.