P R I M E   B A S E   D O O R   R E G I S T R A T I O N   F O R M

   TO:  William Rountree                           Date___/___/___
        7806 Lisa Dr.
        Apt # 203       
        Norfolk, Va.  23518

       (Please use capitalization and punctuation where necessary.)

 FROM:  SysOp Name: _______________________________________________

        BBS Name: _________________________________________________

        Address: __________________________________________________

        City: ______________________ State: __________ ZIP: _______

        Voice: (   ) _________________ BBS: (   ) _________________

        BBS Software: _____________________ BBS Hours: ____________

        Baud Rates:________________________

Current versions as of 7/2/93

SOFTWARE                          VERSION                  PRICE     REG #
--------                          -------                  -----   ----------
Adventurer's Maze.................. 1.60 ................. $20.00  __________

Murder Mansion......................1.70 ..................$20.00  __________

Space Race..........................1.30 ..................$20.00  __________

BBS Putt Putt.......................1.00 ..................$15.00  __________

                                                           ______  (Subtotal)

Discounts: (Circle one if appropriate.)
----------
Order 2 Doors at the same time.......................... - $ 5.00

Order 3 Doors at the same time.......................... - $ 8.00

Order 4 Doors at the same time.......................... - $10.00

                                                         $_______  (Total)

                           F E E D B A C K
                           ---------------

 I learned of BBS Putt Putt from:
           [  ] - A Friend         [  ] - Computer Club
           [  ] - BBS Name & #     [  ] - Compuserve
           [  ] - GEnie            [  ] - Other

 COMMENTS: _____________________________________________________
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