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 UniBank Registration Form                    Version 2.00 

                (Please print clearly!)

REAL Name: _______________________________________

email address: ___________________________________

Mailing Address: _________________________________

__________________________________________________

City: __________________________        State: ___

Zip: _________-_________   Country: ______________


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 Your BBS Information                                      


SysOp Name (Alias?): _______________________________

BBS Name: __________________________________________

Phone: ______________________

Hours: ______________________

FidoNet #: __________________

Other Net #'s: __________________________________

Check here:

[  ]  I have included a valid check or money order for 10
      (ten) U.S. dollars made payable to Jason Peterson.

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 Comments/Suggestions/Bug Reports                          


     _______________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Date: ______________________________________________________

How to do you want to get your registration key?  Check one:

[ ] Email it to me at ______________________________________
[ ] Snail-mail (please include a Self-addressed, stamped envelope)


