MAIL-IN REGISTRATION FORM for TERRITORIES 3069
Complete this form, enclose a check, cashier's check, or money order, and mail
to the address at the bottom of the form.  Please type or print clearly.

FULL NAME: ____________________________________________________________________

  ADDRESS: ____________________________________________________________________

           ____________________________________________________________________

     CITY: __________________________  STATE: _______  ZIP CODE: ______________

    PHONE: (____) ____ - ________  (Please include a day-time phone number.)

 BBS NAME: ____________________________________________________________________

BBS PHONE: (____) ____ - ________

 ЦДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДД·
 є TERRITORIES 3069 ............................................. $   135.00 є
 є OVER-NIGHT SHIPPING (Optional) ...............................       5.00 є
 є WISCONSIN RESIDENTS ADD 5% TAX ...............................            є
 є TOTAL ........................................................ $ ________ є
 УДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДДЅ

PAYMENT TYPE:     Visa    Mastercard      Discover      Payment enclosed

      CHARGE CARD: ________ - ________ - ________ - ________

  EXPIRATION DATE: ____ / ____

YOUR NAME ON CARD: ____________________________________________________________

    BANK OF ISSUE: ____________________________________________________________

 
Mailing address:        Safe Harbor Computers
                        c/o TERRITORIES 3069 REGISTRATION
                        2120 E. Moreland Blvd. Suite L.
                        Waukesha, WI 53186