Registration Form for ECOfax 2.00

Current price for 1 copy of ECOfax: SFr. 65 (sixty five Swiss Francs)
(about US$ 45, forty five US dollars, ask for quantity discounts)

Name: ___________________________________________________

Address: ________________________________________________
         ________________________________________________
         ________________________________________________
         ________________________________________________

Country: ________________________________________________

Phone:   ___________________

FAX:     ___________________

E-mail:  ___________________

Where did you obtain this version of ECOfax?
_____________________________________________

I would like to receive my registered copy of ECOfax

[ ] by mail at the above mentioned address.

[ ] by Internet electronic mail at the following address:
    ___________________________


Payment:

Amount to be paid:
ECOfax, delivered through Internet    SFr. 65.00
+ SFr.10 for mail delivery                ______
+ SFr.10 for cheque payment               ______
TOTAL                                 SFr.
                                          ======

I would like to pay:

[ ] by Credit Card:
    [ ] VISA [ ] Mastercard
    Card Number: ____-____-____-____
    Expiration Date (month/year): __/__
    Name of cardholder: ____________________________________

[ ] by cheque

[ ] by money order to BANCA MIGROS, 6901 LUGANO, SWITZERLAND
    ACCOUNT NO. 16 861.978.1/09

      Eurisco Information Systems
      Via San Gottardo 82
      CH-6900 Massagno
      (Switzerland)

      FAX:    +41 91 966 31 24
      E-mail: info@eurisco.com

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