** UserPoll - The Voting Door for Users **
                 (C) Copyright 1992, by David Polmanteer

Registration Form:

CHECK appropriate space:

$_____  Please rush my UserPoll registration number via U.S. mail.
        I have enclosed my registration fee of $10.00

$_____  Please send my UserPoll registration number via Netmail to
        my FidoNet Address listed below.  I have enclosed my registration
        fee of $10.00

Your name:  ________________________

Sysop name or BBS name as you want it to appear in the main menu
registration notice:

      "Registered To  ______________________________________"

Address:  _________________________________________________________________

City, St, Zip, Country:  __________________________________________________

                         __________________________________________________

Phone Number (voice) :   __________________________________________________

BBS name:  __________________________  BBS Phone number:  _________________

BBS software:  ______________________  Version:  __________________________

FidoNet Address: (for netmailed registration code) ________________________

Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Send payment to:                  Make Check/Money Order Payable to:
                                        David Polmanteer
David Polmanteer                        ~~~~~~~~~~~~~~~~
P.O. Box 190066
Burton, MI
      48519-0066