Registration form for DIMDATA FilePackager Corporate Edition

Program No.:  300055755


Single Copy        at  $59.95 each = ___________
2 to 4 Copies:    at  $49.95 each = ___________
5 to 24 Copies:   at  $39.95 each = ___________
25 Copies:         at  $34.95 each = ___________
Total payment: ___________


Last name: ______________________________________________________

First name: ______________________________________________________

Company:  ______________________________________________________

Street and #: ____________________________________________________

City, State, postal code: ___________________________________________

Country: ________________________________________________________

Phone: _________________________________________________________

Fax:  ___________________________________________________________

E-Mail: _________________________________________________________

*** Please do not forget to include your e-mail address. ***
*** We will use e-mail to communicate with you. ***

How would like to receive the registration code?

[ ] E-Mail  -  [ ] Fax  -  [ ] Postal mail

How would like to pay the registration fee:

[ ] Credit card  - [ ] Wire transfer  - [ ] EuroCheque  - [ ] Cash


Credit card information (if applicable)

Credit card: Visa - Eurocard/Mastercard - American Express - Diners Club

Card holder: ___________________________________________________

Card No.: _________________________ Expiration Date: ______________




Date / Signature: __________________________