1. User information (please PRINT):  *Mandatory

*Name: _________________________________________________________

*Address line 1: _________________________________________________

Address line 2: _________________________________________________

*City: ___________________ *State/Province: _____________

*ZIP/Postal Code: _____________   *Country: ____________________________

Phone number: (___)______________ *Date (MM/DD/YY): ____/____/____

Email address: __________________________________________________

2. Payment and fees:
Fees are in US dollars. Please do not send cash. Your cheque or international money order must be made payable to Richard Timer. Select form of payment (check one):

__ Enclosed cheque
__ Enclosed international money order

3. Please select one of the following options for the delivery of your username and key-code:

__ Email (You must have an email filled in above)
__ Mail

4. Mail this form together with your payment of $19.95 in US Funds to:

P.O. Box 83023
A. Postal Outlet
34-A Avondale Blvd
Brampton, Ont., Canada
L6T 1H0