REQUEST FOR SUPPORT AND/OR REGISTRATION FOR "Belongs2 - Theft Deterrent"
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    Name:     _______________________________________________________________

    Company:  _______________________________________________________________

    Address:  _______________________________________________________________

    City:     ____________________________  State: ____  Zip code: __________

    (outside U.S.A.) Postal code: ________  Country:  _______________________

    Telephone numbers (optional):

              Day:      _____________________________________________________

              Evening:  _____________________________________________________

    CompuServe ID (if response via e-mail is acceptable): __________ , ______

If registering the program:

    Registration fee:
        Initial fee:                1 copies at $ 20 per copy   $       20.00
        Number of lines below: ______ lines at $ 5 per line     $ ___________
        Additional licenses:   ______ systems at $ 1 per system $ ___________

    PA residents add 6% sales tax:                              $ ___________

    Amount enclosed (minimum $25.00)                            $ ___________

If registering the program, list each unique line below.  For multiple copies
with different text, use duplicate line numbers for the line(s) which change.
If requesting support, describe the request below (ignore line numbers):

Line (use additional pages if necessary)

  1 _________________________________________________________________________

___ _________________________________________________________________________

___ _________________________________________________________________________

___ _________________________________________________________________________

___ _________________________________________________________________________

___ _________________________________________________________________________

Signature:

    By signing this form, I certify that I have read and agree to the terms
    and conditions of the License Agreement in the LICAGREE.TXT file.

    Signature:  _______________________________________  Date: ______________

Send this completed form to:

    Robert Simpson
    2839 Dolores Drive
    Library, PA  15129