
PGEN REGISTRATION/ORDER FORM

Remit to:       Keith L. Robertson
                11857 Gloger Street
                Houston, TX  77039-6309

Disk Version Desired:

        IBM:    _____ 5 1/4"-360K       _____ 5 1/4"-1.2M

                _____ 3 1/2"-720K       _____ 3 1/2"-1.44M


Total Number of copies of PGEN needed...................  ______
(If registering multiple copies for more than one user, or if
the registrant's address is different from the shipping address,
please list the names and addresses of all registrants.)


PGEN Registration .....................  $ 20.00 ea  $ ______

For  3 1/2"--1.44M disks, add..........  $  1.00 ea  $ ______

                                           = Subtotal  $ ______

    (Texas residents please add 8% sales tax)     Tax  $ ______


Orders are normally shipped by U.S. Mail at no additional charge.

    For UPS shipment, please add  $ 3.00.....  $ 3.00  $ ______

    For shipments outside the United States,   $ 5.00  $ ______
    please add
                                               = TOTAL   $ ______

Payment by:    ( ) Check    ( ) Money Order

  Ship to:
     Name: _____________________________________________________

  Address: _____________________________________________________

         : _____________________________________________________

City, St : _______________________________  Zip: _______________
(Optional)
Day Phone: _______________________  Eve: _______________________
(Phone is requested in case I have a question about your order.)

(Optional)
I'm always interested in others' applications for PGEN.  If you
care to tell me, please let me know what you are programming.

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