Please fill out this form completely.  Failure to do so will delay your
order.

Please send a check or money order in US Funds ($95) to:

Mark D. Manes
924 Sharon Drive
Chesapeake, VA.  23320

Please fill out the following:

Name of BBS:  ___________________________________

BBS Serial Number: __________________________________
(This is the number FALKEN indicates when it starts up.  If you have a
 shareware version of FALKEN where it says UNREG.000 do not order Shadow
 Realms until you have registered FALKEN BBS)

BBS Telephone Number: _______________________________

Your Name: _________________________________
Address:   _______________________________________
           _______________________________________
           _______________________________________

Your Telephone #: _________________________________

Your handle on Counselor's Couch:  ______________________________

If on FALKENet, which Region/Node: _______________________________
 and what is your handle: _____________________________

Shipment is usually done electronically based on the information you have
provided, and will be uploaded to your BBS.


