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                   Credit Card Registrations 

Be sure to attach the REGISTRATION form from the software you are registering

This form must me mailed for all credit card registrations.  When registering
on 21st Century Support BBS, a signed form must be received for order 
confirmation.

Name:

Company:


Address:



City:                      State:                   Zip:


Telephone:

Fax:


 Software & Registration Price  _______________    _________             

        TX residents 
          TAX (7 1/2 %)                            __________

                  
                  Total                             __________


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Card Information


               Select one:    VISA      MASTERCARD


              Card Number:

           Expiration Date:

       Name of Card Holder: 
(as it appears on the card)

              
      Bank or Card Service:        
              
              Total Amount:



Date:                          Signature:




A charge to 21st Century Communications will appear on your billing.



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Please supply a way for us to send you the registration key:

- Fax
- Fido
- Internet e-mail
- Mail (please note the surcharge above!)


