* * * *   LOPAKA'S BLACKJACK DOOR REGISTRATION FORM  * * * *

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

     Registration Fee: $10.00 (U.S. Funds)

                                                          DATE:   /  /

     BBS Name: ___________________________________________________________

     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 BlackJack door that I have is : _.__

     Comments: ____________________________________________________________

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   * (Please make your checks payable to Robert Fortune)