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Text File  |  1996-04-19  |  2.0 KB  |  59 lines
  1.  
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  3.  
  4.                                    BMT Micro
  5.                            FastLst Registration Form
  6.  
  7.                    *****************************************
  8.                    * DO NOT SEND this form to the author ! *
  9.                    *****************************************
  10.  
  11.       See Register.Doc for instructions, please PRINT:    Date: __/__/__
  12.         
  13.       Name: ____________________________________________________________
  14.         
  15.       Company: _________________________________________________________
  16.  
  17.       Address: _________________________________________________________
  18.         
  19.       __________________________________________________________________
  20.         
  21.       City: _______________________   State/Province: __________________
  22.  
  23.       Country: ____________________________ Postal Code: _______________
  24.  
  25.       Phone: ___________________________________________________________
  26.  
  27.       Fax: _____________________________________________________________
  28.         
  29.  
  30.                             REGISTRATION INFORMATION
  31.  
  32.       Reg.: ____________________________________________________________
  33.         
  34.       e-mail to: _______________________________________________________
  35.  
  36.       Netmail to: ______________________________________________________
  37.         
  38.       Crash to: ________________________________________________________
  39.         
  40.  
  41.       Product: FastLst (by Alberto Pasquale)           Price:  US$ 25.00
  42.  
  43.       North Carolina residents, please add 6% sales tax:      +US$  1.50
  44.  
  45.                                                        Total:  US$ __.__
  46.  
  47.       For credit card payment only:
  48.  
  49.       Circle one: VISA / Master / Discover / AMEX / Diner's Club
  50.  
  51.       Credit card number     : _________________________________________
  52.  
  53.       Expiration date        : ___/___
  54.  
  55.       Authorization signature: _________________________________________
  56.  
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