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  1. Internet Database Registration Form
  2. -----------------------------------
  3.  
  4. Please fill out the following information and send it the address below along with your check or money order (sorry no Credit Cards yet).
  5.  
  6. Prices
  7. ------
  8. $10.00 Canadian if you live in Canada.
  9.  
  10. $10.00 US if you live anywhere else.
  11.  
  12. Add $5.00 If you would like a disk with the latest version sent to you.
  13.  
  14. Fill This Out
  15. -------------
  16.  
  17. Name:_____________________________________________________
  18.  
  19. Company:__________________________________________________
  20.  
  21. Address:__________________________________________________
  22.  
  23. __________________________________________________________
  24.  
  25. City:_____________________________________________________
  26.  
  27. Province/State:___________________________________________
  28.  
  29. Postal/Zip Code:__________________________________________
  30.  
  31. Country:__________________________________________________
  32.  
  33. Phone:____________________________________________________
  34.  
  35. Fax:______________________________________________________
  36.  
  37. E-Mail:___________________________________________________
  38.  
  39. Would you like a receipt?_________________________________
  40.  
  41.  
  42. Send It To
  43. ----------
  44.  
  45. John Luciani
  46. Fusion Design
  47. 975 Warwick Court, Suite 1608
  48. Burlington, Ontario
  49. L7T 3Z7
  50. Canada
  51.  
  52. Please make cheques payable to: John Luciani
  53.  
  54. My E-mail address is: bats@wchat.on.ca
  55.  
  56. Visit my Home Page: http://wchat.on.ca/web/bats/bats-m.htm
  57.