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Text File  |  1998-04-22  |  2KB  |  49 lines

  1.                            BLIZZ E-MAIL
  2.                         REGISTRATION FORM
  3.  
  4.                  Print this form and complete it.
  5.       Once completed, send it by fax at 514-359-7060 (Canada)
  6.                       Please write clearly. 
  7.  
  8.  NAME:       _____________________________________________________
  9.  
  10.  E-MAIL:     _____________________________________________________
  11.  
  12.  COMPANY:    _____________________________________________________
  13.  
  14.  ADDRESS:    _____________________________________________________
  15.  
  16.              _____________________________________________________
  17.  
  18.  CITY:       _____________________________________________________
  19.  
  20.  STATE:      _____________________________________________________
  21.  
  22.  COUNTRY:    _________________________ ZIP CODE:   _______________
  23.  
  24.  TELEPHONE:  _____________________________________________________
  25.  
  26.  
  27.                   Blizz E-Mail Cost (5 users version):
  28.  
  29. AMOUNT: 69.99$Can x  NUMBER OF COPIES: _____  TOTAL: _________$Can
  30. (note: Depending on exchange rate, 69.99$Can is about 49.99$US)
  31.  
  32.  
  33.   Payment method: Check       ____        TO: BLIZZ INFORMATIQUE
  34.                   Money order ____            446, du Blizzard
  35.                   VISA        ____            St-Luc, Qc, CANADA
  36.                                               J2W 1Y4
  37.  
  38.  
  39.   SIGNATURE: _________________________________________________
  40.   Note: For each registration we will contact you by e-mail.
  41.  
  42.  
  43.  FOR VISA PAYMENT:
  44.  =================
  45.  NUMBER:            _________________________ EXPIRY DATE:________
  46.  
  47.  NAME ON THE CARD:  ______________________________________________
  48.  
  49.