Data-Trak's Setup Program

REGISTRATION FORM

Copyright 1993 Data-Trak, Inc.
P.O.Box 956
Freeport, TX  77541-0956
Telephone (409) 233-0121
CompuServe Account - 73374,502


Name_________________________________________________

Company (if applicable)______________________________

Suite, Apt., etc.____________________________________

Mailing Address______________________________________

_____________________________________________________

City_________________________State____Zip_______-____

Telephone (_____)  ____-________

CompuServe Account (If desired)________,_____


Registration Fee          $25.00 
Texas Residents add              
7.75% sales tax ($1.94)   $_____ 
Total Registration        $_____ 

Enclose check or money order for the total registration drawn on U.S. funds payable to Data-Trak, Inc. and mail to the above address.

Program was obtained from:

___ Compuserve  
___ America Online      
___ Other (specify) _________________

THANK YOU FOR YOUR ORDER.
