REAL VIDEO POKER for Windows 95 REGISTRATION

          Name        ____________________________________________

          Company     ____________________________________________

          Address     ____________________________________________

          City/State  ____________________________________________

          Zip Code    _________  Country _________________________

          Phone      (    ) ____-______  EMail ___________________

         EMail       _____________________________________________

     DISK SIZE:  (  ) 3-1/2" Diskette     (  ) CD-ROM Disc

     I AM ORDERING:
              (  ) REAL Video Poker ($20)
              (  ) REAL Video Poker and REAL Video Blackjack ($25)
              (  ) REAL Video Poker & BJ and Noisy Video Poker & BJ ($30)

     SHIPPING CHARGES
     --------------------
     Please add $2.00 for shipping if you live in the United States.
     For shipping to all other countries, please add $4.00 per order.

     Amount Enclosed: $_________

     Make your check or money order payable to ULTISOFT.

     Mail payment and registration form to:    ULTISOFT
                                               PO Box 5015
                                               Central Point, OR 97502
                                               USA
     Payment Method:
                     ___ Check   ___ Money Order   ___ VISA   ___ MasterCard

     Credit Card Number #_____ - _____ - _____ - _____   expires ____/____

     For credit card orders:  Call 1-800-925-3147 (U.S. and Canada)
                                   1-541-664-1885 (International)
                                   1-541-664-3403 (FAX)

     Order Online at:         http://www.ultisoft.com