My Little Realm Order Form

          Name 
          Last: ___________________________  First: ________________  M.I. ___
                   
          Address: ___________________________________________________________

          City: _________________________________________  State: ____________

          Zip: ________________ Home Phone: (________) _______________________
          
          ____________________________________________________________________

                  DizzE The DIZ Editor           _____    $10        _________
          ____________________________________________________________________
             
                                              Shipping/Handling   __$5.00__
             
                                                       Subtotal   _________
           
                   New Jersey residents please add 6% sales tax   _________
             
                                       Total amount of purchase   _________
          ____________________________________________________________________
          
          Disk size:   _____   5 1/4"   _____   3 1/2"    (Disks are DS/DD)
          ____________________________________________________________________
          
          Please make your check or money order out to:  
                              
                              John L. Salisbury 
                              22 Church Street #103, Suite 376
                              Ramsey, New Jersey 07446

          Checks and money orders must be drawn on U.S. banks in U.S. funds.
          Sorry, phone orders cannot be accepted.  Prices subject to change.
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