GoMac 1.2 Registration Form

Send this form with payment to: Proteron
                                Attn: GoMac Sales
                                9600 East 150 Highway
                                Kansas City, MO 64149

Internet registration at http://www.proteron.com/gomac

====================== Registration Information ======================

<LastName>, <FirstName> <MI>
<Company>
<Address1>
<Address2>
<City>, <State> <Zip>
<Country>
*EMail: <EMail>

------------------------ Purchase Information ------------------------

Purchase Quantity: <Copies> copies
     <Copies1995> at $19.95
     <Copies0500> at  $5.00

Bulk Purchase Price:
     <Copies1495> at $14.95


Total cost: <Total>

------------------------ Payment Information -------------------------

**Payment Method: <Pmt>

Credit Card Information
  Name on Card: <CCName>
  Card Number:  <CC#>  Exp. Date:    <ExpDate>

First Virtual Information
  FV Account: <FV#>

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*If you include an email address, you will receive your serial number
via email within 48 hours after we receive this form.
**REMEMBER: If paying by Check/Money Order, be sure to include payment.