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Text File  |  1994-05-19  |  2KB  |  62 lines
  1.     Joe Malkin
  2.     PO Box 2024
  3.     Houghton
  4.     2041
  5.     South Africa
  6.  
  7.     Name     ______________________________________________________________
  8.  
  9.     Address  ______________________________________________________________
  10.  
  11.              ______________________________________________________________
  12.  
  13.     City     ____________________________ Prov/State _______ Code _________
  14.  
  15.     Country  ______________________________________________________________
  16.  
  17.     Telephone Numbers: Voice (_____)____________   Data (_____)____________
  18.  
  19.     Internet/Fidonet address ______________________________________________
  20.  
  21.  
  22.     Please licence me to use CLEANQWK.  I would like to place my order as
  23.     follows:-
  24.  
  25.     _____ South African Registration(s)             @   R 20     __________
  26.  
  27.     _____ Non-South African Registration(s)         @ US$ 10     __________
  28.  
  29.                                                                  ==========
  30.        Total (cheque or money order enclosed)
  31.                                                                  ==========
  32.  
  33.  
  34.     Where did you obtain CLEANQWK?    _____________________________________
  35.  
  36.  
  37.     Additional Names and Addresses (if more than one registration):-
  38.  
  39.     2) ____________________________________________________________________
  40.  
  41.     3) ____________________________________________________________________
  42.  
  43.     4) ____________________________________________________________________
  44.  
  45.     5) ____________________________________________________________________
  46.  
  47.     6) ____________________________________________________________________
  48.  
  49.     7) ____________________________________________________________________
  50.  
  51.     8) ____________________________________________________________________
  52.  
  53.  
  54.     Comments and Suggestions ______________________________________________
  55.  
  56.     _______________________________________________________________________
  57.  
  58.     _______________________________________________________________________
  59.  
  60.     _______________________________________________________________________
  61.  
  62.