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Text File  |  1994-02-06  |  818b  |  24 lines
  1.  
  2.                            MEDITRAK V3.21
  3.                            --------------
  4.    
  5.                         ORDER/REGISTRATION FORM
  6.                         -----------------------
  7.  
  8. NAME: ______________________________   ADDRESS: _____________________________
  9.  
  10. CITY: __________________  STATE: __   ZIP: __________  PHONE: _______________
  11.  
  12. COUNTRY:______________ WHERE DOWNLOADED:_____________ SCREEN NAME:___________
  13.  
  14. TYPE OF COMPUTER: _________________________    TYPE OF PRINTER: _____________
  15.  
  16.  
  17. QTY: ___   IBM DISK SIZE: ______  COST: $14.95 (US)  TOTAL: ___________
  18.  
  19. SHIPPING/HANDLING:  US/CANADA ..................................   3.00
  20.  
  21.                     OTHER ......................................   5.00
  22.  
  23.  
  24. TOTAL AMOUNT TO SEND (US FUNDS ONLY) ............................ ______