Registration form for DIMDATA FilePackager Professional Edition

Program No.:  195112

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: __________________________