******************************************************
            **    Grapevine Amiga Internet Relay Chat Client    **
            **               User Registration Form             **
            ******************************************************

  Mail to:  Brian J. Cerveny
            406 30th Street N.W.
            Cedar Rapids, IA  52405-3622
            USA


     Name: __________________________________________________________________


  Address: __________________________________________________________________


     City: ____________________________ State/Province: _____________________


  Country: ________________________________ Telephone (USA): ________________


   E-mail: __________________________________________________________________

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  Registration of Grapevine entitles you to free upgrades to all future
  major versions of the program, including one (1) disk mailing.  Updates
  after the first mailing will be distributed online, or by mail for a charge
  of $5 for the disk and shipping costs.

  The cost of registration is $25 in United States currency.  Accepted forms
  of payment are U.S. cash currency, bank or postal money order drawn in
  U.S. funds, and certified check in U.S. funds.

  Personal cheques are NOT accepable for payment.

  ***************************************************************************

  ORDER:
  
           Grapevine Registration:   $25 U.S.
                                                                 
      Payment method (CIRCLE ONE):   (1) U.S. currency

                                     (2) Money order

                                     (2) Cashier's check

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  I agree to all terms outlined in the LICENSE section of the Grapevine user
  manual and to the terms of registration named above.
  
  
    ___________________________________________     _________________________
                      Signature                                Date