Steve Jackson
412 S. Willaman Dr. #504
Los Angeles, CA 90048-3990
U.S.A.

                              
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                  REGISTRATION FORM FOR THE WEB MEDIA PUBLISHER 
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           Name: ___________________________________________

   Company Name: ___________________________________________

        Address: ___________________________________________





   Phone Number: ___________________________________________

 E-Mail Address: ___________________________________________
                          

Additional comments, etc:

____________________________________________________________

____________________________________________________________

____________________________________________________________


Registration is $35 (U.S. Dollars Only). 
International Orders add $5 if paying by Check or Money Order 
drawn on a bank outside of the U.S. (Canadians included).

Send this order form (or same information) along with your payment to: 

Steve Jackson  
412 S.Willaman Dr. #504 
Los Angeles, CA 90048-3990

Checks must be made out to: Steve Jackson
(checks made out to Web Media, etc. are not valid and 
will be returned to sender - delaying the registration key).

You will receive email with your Registration Key shortly after
payment is received.

You may register with VISA or MasterCard.  
Please visit http://www.wbmedia.com/publisher  
or e-mail cc@wbmedia.com for more information.

