Yes, I want to register as a user of RepPoc 1.20.

Name: _________________________________________

Address: ______________________________________

Town: ____________________________ State: ____   ZIP: ____

Country: ______________________________________


I have obtained RepPoc through:

	_  an electronic network or bulletin board

	   Please give name of network __________________

	_  through a shareware organisation

	   Please give name of organisation __________________

	_  from a dealer

	_  from a friend

	_  Other

I use RepPoc for:

	_  business purposes

	   Please indicate nature of business _____________________

	_  personal purposes

	_  as software developer


I have added the amount of US$ 20.00 in the form of

	_  a personal cheque (Australia only)

	_  a cheque made payable to an Australian bank

	_  Eurocheque (in the currency of my country)

	_  money order


Signature ____________________________    Date _______________