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Text File  |  1991-04-07  |  2KB  |  64 lines
  1. -------------------------------------------------------------------------------
  2.  
  3.                         FLU_SHOT+ (V1.82) Registration
  4.  
  5. Please fill out this form, then mail it along with a check for $19 ($15
  6. Registration, $4 Shipping/Handling/Processing) or with authorization
  7. to charge this amount to your credit card to:
  8.  
  9.                          Ross M. Greenberg
  10.                          Software Concepts Design
  11.                          594 Third Avenue
  12.                          New York, New York 10016
  13.                          FAX: (212)-889-9730
  14.  
  15. Thanks for your support!
  16.  
  17.         Name:_________________________________________________________
  18.  
  19.         Title:________________________________________________________
  20.  
  21.         Company:______________________________________________________
  22.  
  23.         Address:______________________________________________________
  24.  
  25.                 ______________________________________________________
  26.  
  27.         City:   _____________________     State: _________  Zip:______
  28.  
  29.         Telephone:________________________        [__] 5.25" [__] 3.5"
  30.  
  31.         Number of copies:  __________ x $15  =     $________.____
  32.             Shipping and Handling:               + $       4.00
  33.                                                    ==============
  34.             Total of Order:                        $________.____
  35.  
  36. [__] Check Enclosed for the above amount.
  37.  
  38. [__] Bill my Credit Card (MasterCard or Visa Only) for the above amount.
  39.  
  40.        ___________________________________________       _______________
  41.                    Credit Card Number                    Expiration Date
  42.  
  43.  
  44. Comments and Suggestions:____________________________________________________
  45.  
  46.          ____________________________________________________________________
  47.  
  48.          ____________________________________________________________________
  49.  
  50.          ____________________________________________________________________
  51.  
  52.  
  53. Where did you get FLUSHOT+ (V1.82) from? (check one, fill in the blank):
  54.  
  55.         [__]  User Group  (which one:________________________________________)
  56.  
  57.         [__]  BBS  (Name:_______________________)(Tel #:_____________________)
  58.  
  59.         [__]  Other (Such as:________________________________________________)
  60.  
  61.  
  62. [__]    Please send me more information RamNet, the background
  63.         communications program. 
  64.