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1997-06-06
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4KB
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59 lines
Fax this form to (US/CAN): (800) 936-5177 (No Cover Sheet Required)
For International Faxes: (770) 612-9855 (US Number)
Or mail this form to: Theatrix Registration, c/o IntelliQuest Communications
PO Box 671499, Marietta, GA 30006-0025
============================================================================
XXX:JLSXJJLJJJLJ
First Name: $(personal.201,20) MI: $(personal.202,2)
Last Name: $(personal.203,30)
Address 1: $(personal.204,35)
Address 2: $(personal.205,35)
City: $(personal.206,20) Pdte: $(marketing.302,10)
State: $(personal.207,20) Zip: $(personal.209,10)
Province: $(personal.208,20) Country : $(personal.600,20)
Phone: $(personal.210,20) Fax: $(personal.211,20)
Email: $(personal.212,50)
This form will be scanned by a computer. Do not make any changes to this form.
NOTE: Some information has been encoded to guarantee accurate transmission.
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IBMc: $(marketing.2001,3) Wn31: $(marketing.2008,3) Osys: $(marketing.3005,20) Home: $(marketing.1101,3)
MacT: $(marketing.2002,3) Wn95: $(marketing.2009,3) Mftr: $(marketing.3001,20) Schl: $(marketing.1102,3)
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Pent: $(marketing.2007,3) Sys7: $(marketing.2011,3) MBRm: $(marketing.3003,4)
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PwPC: $(marketing.2006,3) NmSc: $(marketing.301,15)
Wbuy: $(marketing.303,30) Opu1: $(marketing.1001,25)
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OtOL: $(marketing.801,30) Opu3: $(marketing.1003,25)
OtPd: $(marketing.901,30) OthT: $(marketing.3000,20)
XXX:JLSXJJLJJJLJ