Registration form for Geo Applets

Program No.: 102060

Last name: ___________________________________

First name: ____________________________________

Company: ____________________________________

Street and #: ______________________________________

City, State, postal code: ________________________________

Country: _______________________________________

Phone: _____________________________________

Fax: ________________________________________

E-Mail: ______________________________________

How would like to receive the registration key/full version?

e-mail - fax - postal mail

How would you like to pay the registration fee of $12:

credit card - wire transfer - EuroCheque - cash

Credit card information (if applicable)

Credit card: Visa - Eurocard/Mastercard - American Express - Diners Club

Card holder: ________________________________

Card No.: ___________________________________

Date of Expiration : ___________________________________

Date / Signature ___________________________

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