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  1.                                  ORDER FORM
  2.                                  ----------
  3.  
  4.         To receive a registered copy of Video Keno, please send this 
  5. completed form along with cash, check, or money order(U.S. Funds) for $7.50
  6. per copy to:
  7.             James R. Christie, Jr.
  8.             16018 Frederick Plaza
  9.             Omaha, NE 68130
  10.             U.S.A.
  11.  
  12.  
  13. Please check desired disk size:  3.5"_____      5.25"_____
  14.  
  15. Your name:__________________________________________________________
  16.  
  17. Street Address:_____________________________________________________
  18.  
  19. City:____________________________
  20.  
  21. State:___________
  22.  
  23. Zip Code:___________________
  24.  
  25.  
  26.