* * * *   [LOPAKA'S] BBS VIDEO POKER DOOR (v1.02) REGISTRATION FORM  * * * *

     Mail to:  Robert Fortune
               48 West 17th Street, #B303
               New York, N.Y. 10011-5726
               USA

     Registration Fee: $15.00 (U.S. Funds)


  [ ] Hey Robert, check your records! I registered Lopaka's BBS BlackJack\21
      door on or before October 15, 1995 so give me that special $5.00 off
      registration offer (only $10.00) for BBS Video Poker!


                                                          DATE:   /  /

   * BBS Name: ___________________________________________________________

     BBS names should be 25 characters or less and should be given in upper
     and lower case letters as in:  The Tropic Isles

     First Name: ______________________     Last Name: ___________________

     BBS Phone Number: ___________________________________________________

     (Node 2)          ____________________________________________________

     (Node 3)          ____________________________________________________

     BBS Software: ________________________________________________________

     Street Address: ______________________________________________________

     City: _____________________  State: __________________ Zip: __________

     Country: __________________

     Voice Number: (   ) _____________ [Optional]

     Version of [LOPAKA'S] BBS VIDEO POKER door that I have is : _.__


     Comments: ____________________________________________________________

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   * (Please make your checks payable to ROBERT FORTUNE in U.S. funds)