Purity Door Registration Form Name _________________________________________________________________________ Address ______________________________________________________________________ City ________________ Province/State ___________ Postal/Zip Code _________ Country _________ Phone # - Voice ___________________ Data _________________ BBS Name & Phone Number(s) (As will be in Registration Key): ______________________________________________________________________________ How would you like your key sent? (As soon as Cheque clears... 8) ) ( ) Postal Mail - ( ) 3-1/2 inch ( ) 5-1/4 inch Diskette (* Please add $5 P&H *) ( ) Fido Crash/Netmail - Address: ( ) Internet UUEncoded - Address: ( ) Download from my BBS (Will be available under your FULL NAME) Password for your account:_________________ Is this your BBS or are you "Adopting" this BBS (Circle one)? Sysop Adopt If adopting, what name would you like to have shown (leave blank for real name) ______________________________________________________________________________ NOTE: Please be sure to make out Cheque or M.O. (preferably), for $1O, to: ALLEN WALKER, P.O. Box 5874, Victoria, B.C, Canada, V8R 6S8 旼컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴� � If you want to pay for the door by VISA, I will need the following info: � � � � Name (exactly as on Card): ________________________________________________ � � � � Visa Number: __________________________________ Expiry date: ___________ � � � � Since the VISA is charged in Canadian Funds, the following amounts apply: � � � � Canadian Orders: $1O.OO � � U.S. Orders: $13.OO � � � � Postage & Handling: $5.OO � � (P&H only applies to me mailing you your Registration & Disk) � � � � Total Charge: $___________ � � � 읕컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴� What would you like to see in future doors: ( ) Rip Graphics ( ) Simple, Addictive Games ( ) Puzzle/Mind Games ( ) More Ansii ( ) Complex Strategy Games ( ) Kids Games ( ) Utility Doors ( ) Adult/R-Rated Games ( ) Action Games Comments/Suggestions: