DOUBLE DOWN VIDEO POKER v1.0 REGISTRATION FORM


        All prices are in U.S. funds and effective from 04/08/91.

    
               Item                    Quantity  Price      Amount 

DOUBLE DOWN VIDEO POKER on a 5¬" disk  ________  $10.00     _______

DOUBLE DOWN VIDEO POKER on a 3«" disk  ________  $10.00     _______

Printed Manual                         ________   $1.00     _______

    Subtotal                                                _______

California Residents Add 6.5% tax                           _______

    TOTAL                                                   _______

Check or money orders only.  Checks drawn on Non-U.S. banks or in Non U.S 
funds cannot be accepted. Checks must be in U.S. Funds drawn from a U.S 
Bank. 

Name:         ___________________________________________

Address       ___________________________________________

              ___________________________________________

City          ________________________  State  _______ ZIP ___________ 

Country       ___________________________________________

Phone (      )  _________ - _________________  (optional)

Send this form with payment to:  

Sam Hazan
11929 Weddington Street #303
North Hollywood, CA  91607
U.S.A.

Please allow 2-3 weeks for delivery.