Registration Form

NRich (tm)

NRGraphX 
version1.1a 


Date (MM/DD/YY): __/__/__

1. Information: please complete/include all that's applicable

Name: ___________________________________________________________
Address:_________________________________________________________
City: ___________________________________________________________ 
Prov / State: __________________ (2 letter abbreviation prefered)
Postal Code /ZIP: ___________
Country (if other than Canada / US): ____________________________
Phone number: (___)______________ 
E-mail address (if applicable):__________________________________

Rep#(on startup screen): ________________________________________
(important to include this to compensate the representative for 
 his/her work)

Do you wish to become a rep for NRich(tm)?
(Default option is Yes)
__ Yes
__ No


2. Shipping and Handling (check one):

__ E-mail to e-mail address above.
__ Mail 3.5'' DS/HD disk, site name and ID to address above.

3. Payment and fees:

Fees are in U.S. dollars for all, 
except for 
Canadian residents, who can pay in Canadian funds.
Canadian residents add appropriate sales tax. 

Please do not send cash. 
Checks and money orders only.

Checks and money orders must be made payable to:
David J.Toms 

Select form of payment (check one):
__ Enclosed check or money order in Canadian dollars
__ Enclosed check or money order in U.S. dollars


4. Pricing for the use of NRGraphX per site computer 

__ 1st computer at $25:............................... = $ 25.00
__ 2nd or greater at $15 each:.............. ____ x 15 = $______
__ Total U.S. Shipping and handling (if not E-mail)..... $______
__ Total Non U.S. Shipping and handling (if not E-mail). $______
__ Canadians add appropriate sales tax.................. $______

    Total:.......................................... $______

5. Mail this form together with payment to:

	David J. Toms
	NRGraphX Registration
	P.O. Box 237
	Bishop's Falls, NF
	CANADA
	A0H 1C0



	NOTE: 	make sure you make payment out to: 
		David J. Toms