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Text File  |  1999-05-09  |  2KB  |  69 lines
  1.                     POTIK SOFTWARE REGISTRATION FORM
  2.  
  3.    Product Name: Dr. Associate________________________________________
  4.  
  5.      Product ID: 11040________________________________________________
  6.  
  7.            Please don't forget to sign at the end of this form.
  8.            Please anwser questions required for registration.
  9.  
  10.            Name: _____________________________________________________
  11.  
  12.         Company: _____________________________________________________
  13.  
  14.          E-mail: _____________________________________________________
  15.  
  16.        WWW Page: _____________________________________________________
  17.  
  18.         Address: _____________________________________________________
  19.  
  20.       City/Town: _____________________________________________________
  21.  
  22.  State/Province: _____________________________________________________
  23.  
  24.   Post/Zip Code: _____________________________________________________
  25.  
  26.         Country: _____________________________________________________
  27.  
  28.           Phone: _____________________________________________________
  29.  
  30.                 (e-mail if you want a multilicence with special price)
  31.  
  32.                                             US Dollars or Deutsche Mark
  33.                                             ($7 each)     (DM 10 each)
  34.        Quantity: _________________ copies = $_________    DM _________
  35.  
  36.  Send registration key via: (Please check)
  37.  
  38.  [ ]  mail to above postal address        + $3________  + DM 5________
  39.  
  40.  [ ]  E-Mail to above address             + $0________  + DM 0________
  41.  
  42.                              Total payment: $_________ or DM _________
  43.  
  44.  Send information on E-Mail: (Please check)
  45.  
  46.  [ ]  don't send any information
  47.  
  48.  [ ]  send notification about new version
  49.  
  50.  [ ]  send upgrade to new version (about 200 kB)
  51.  
  52.  
  53.  
  54.  USER SIGNATURE: ________________________________________
  55.  
  56.    Today's date: __/__/1999
  57.  
  58.            Send this form to potiksw@seznam.cz
  59.  
  60.            or print it clearly and send it to:
  61.  
  62. Send your registration fee to:   Daniel Kejval
  63.                                  Cs. odboje 674
  64.                                  51801 Dobruska
  65.                                  Czech Republic
  66.  
  67.  Don't worry about sending cash in the mail, just fold it into a sheet 
  68.  of paper so that you can't see the money through the envelope.
  69.