                         Registration Form For RGBACK


NAME:

ADDRESS:

CITY/STATE:

ZIP CODE:

BBS PHONE:

NAME OF THE BBS:

HOW LONG IT'S BEEN RUNNING:

Registration of RGBACK is $ 5.00 in US Dollars.

Method of payment     CHECK (  )    Money Order (  )  Credit Card (  )

Credit Card Type     Visa (  )  MC (  )  Novis/Discover (  ).

Credit Card Number __________________________________________

Expire Date  ____/____

Signed ______________________________________________________




