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Text File  |  1992-05-01  |  3KB  |  64 lines
  1.  
  2.         REGISTRATION FORM
  3.         ───────────────────────────────────────────────────────────────────
  4.                    
  5.           Registration Fee      $15.00                         $  ____________
  6.           Shipping & Handling   $ 2.50                         $  ____________
  7.                                                                ---------------
  8.           Total                                                $  ____________
  9.                
  10.         I wish to pay by 
  11.         
  12.            [__] Check (US Funds / US Bank) - Made payable and sent to Peiman 
  13.                 & Associates, Inc., P.O. Box 948219, Maitland, Florida, 32794.
  14.            [__] Credit Card - Fill in the credit card information below.
  15.         
  16.         
  17.         We will either send the registered version or you can download it along
  18.         with your registration key file from, The DOOR BBS, (Tm) & Information
  19.         Network at  407-682-3132, (3-Nodes, USR DS/V.32bis/HST).
  20.         
  21.         Please Check the Appropriate box:
  22.              [__] I wish  my  copy  sent  via US  Mail.   Pick  one  of  the 
  23.                   following medias (  ___ 5.25"    ___ 3.5"  )
  24.              [__] I wish to download my copy.
  25.         
  26.         
  27.         Complete ALL of the following information:
  28.         
  29.         Sysop Name: _____________________________________________
  30.         
  31.         Board Name: _____________________________________________
  32.         
  33.            address: _____________________________________________
  34.         
  35.                     _____________________________________________
  36.         
  37.               City: _____________________________________________
  38.               
  39.              State: ___________  ZIP: ___________ Phone: ___________________
  40.         
  41.         
  42.         (For Downloads Only)
  43.         Username: ___________________________________________
  44.         
  45.         Password: ___________________________________________
  46.         
  47.         
  48.         (For Credit Card Purchases)
  49.         
  50.         Name : _____________________________________________________________
  51.                (as it appears on your credit card)
  52.         
  53.         Type of Card :   ___ Mastercard   ___ Visa   ___ Diner's Club
  54.          
  55.                          ___ Carte Blanche
  56.         
  57.         Exp Date : ______    Issuing Bank : ________________________________
  58.         
  59.         Signature : ________________________________________________________
  60.            
  61.                     Send to:   Peiman & Associates, Inc.
  62.                                629 Peachwood Drive
  63.                                Altamonte Springs, FL. 32714
  64.