To: Fantaisie Software
             10, rue de Lausanne
             67640 Fegersheim
             France

     ********************************* PureBasic x86 ****************************

            I would like to purchase the full version of PureBasic.

     Price per copy: 59 Euro

     Name:    _________________________________________________________

     Address: _________________________________________________________

              _________________________________________________________

              _________________________________________________________

     Country: _________________________________________________________

     Phone:   _________________________________________________________

     EMail:  _________________________________________________________

     All requested information is considered private and personal. It will not be 
     distributed for any reason by Fantaisie Software.

     I am sending the shareware donation via (please mark as appropriate):-

       ( ) Euro cheque. The safer/cheaper method for all European people.

       ( ) Other methods? Prior approval required via EMail. (Approvals will be
           kept as confirmation pending receipt of the registration form).


     Please send me the full programme via (please mark as required):-

       ( ) EMail (MIME encoded file)

       ( ) Snail Mail (on CD-Rom)

     I have read the terms and conditions and agree to abide by them.


     __________________     ________________________________________

         Date                              Signature



     Notes about PureBasic: