POTIK SOFTWARE REGISTRATION FORM

   Product Name: Dr. Associate________________________________________

     Product ID: 11040________________________________________________

           Please don't forget to sign at the end of this form.
           Please anwser questions required for registration.

           Name: _____________________________________________________

        Company: _____________________________________________________

         E-mail: _____________________________________________________

       WWW Page: _____________________________________________________

        Address: _____________________________________________________

      City/Town: _____________________________________________________

 State/Province: _____________________________________________________

  Post/Zip Code: _____________________________________________________

        Country: _____________________________________________________

          Phone: _____________________________________________________

                (e-mail if you want a multilicence with special price)

                                            US Dollars or Deutsche Mark
                                            ($7 each)     (DM 10 each)
       Quantity: _________________ copies = $_________    DM _________

 Send registration key via: (Please check)

 [ ]  mail to above postal address        + $3________  + DM 5________

 [ ]  E-Mail to above address             + $0________  + DM 0________

                             Total payment: $_________ or DM _________

 Send information on E-Mail: (Please check)

 [ ]  don't send any information

 [ ]  send notification about new version

 [ ]  send upgrade to new version (about 200 kB)



 USER SIGNATURE: ________________________________________

   Today's date: __/__/1999

           Send this form to potiksw@seznam.cz

           or print it clearly and send it to:

Send your registration fee to:   Daniel Kejval
                                 Cs. odboje 674
                                 51801 Dobruska
                                 Czech Republic

 Don't worry about sending cash in the mail, just fold it into a sheet 
 of paper so that you can't see the money through the envelope.