FAX Registration Form
---------------------

From
    Name:  _____________________________

    Phone: _________________________

    FAX:   _________________________

To
    Name:  PalmGear H.Q.

    Phone: (800)741-9070

    FAX:   (817)640-6614


RE: Flytrap registration


Please register me for Flytrap as follows:

    HotSync username: _____________________________

    Email address:    ______________________________________

Please bill $10 to my credit card as follows:

    Credit card:  [ ] VISA   [ ] MasterCard   [ ] American Express

    Credit card number:  _____________________________

    Expiration date:     ____________

    Name on credit card: _____________________________

    Billing address:     _________________________________________

                         _________________________________________

    City:                _____________________________

    State:               ___________________

    ZIP:                 ___________________

    Country:             ___________________

----End of Form----