
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 order3. 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)
__ Mail4. 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