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| Street Shuffle Registration Form                                           | 
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| Please complete all questions in this section:                             |
|                                                                            |
| Name:_____________________________________________________________________ |
|                                                                            | 
| Street Address:___________________________________________________________ |
|                                                                            |
| City:________________________________ State:________ Zip:_________________ |
|                                                                            | 
| What type of diskettes do you require? (Check one):                        |
| 3 1/2" DS/HD (1.4 mb) 1 disk ___         3 1/2" DS/DD 2 disks (720 kb) ___ |
| 5 1/4" DS/HD (1.2 mb) 1 disk ___         5 1/4" DS/DD 4 disks (360 kb) ___ |
|                                                                            | 
| The registration fee for Street Shuffle is $7.00 US + $3.00 Shipping and   |
| Handling.  You need not include the Shipping and Handling fee if you       |
| include the needed blank diskettes and a self-addressed, stamped envelope. |
|                                                                            | 
| Check One:                                                                 |
| I have enclosed payment of $10.00 ___                                      |
| I have enclosed payment of $7.00, all diskettes and an SASE ___            |
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| Completion of the following information is optional:                       |
|                                                                            | 
| What version of Windows (or OS/2) are you using?:______                    |
|                                                                            | 
| Where did you obtain this copy of Street Shuffle?:                         |
| Bulletin Board Service: Name:______________________ Phone #:______________ |
| Friend:___                                                                 |
| Other:____________________________________________________________________ |
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| Any questions, comments, or future changes you would like to see made?:    |
| __________________________________________________________________________ |
| __________________________________________________________________________ |
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| Send your check or money order payable to Max Eissler and this form to:    |
|                                                                            | 
|                                             Street Shuffle Registration    |
|                                             4645 East Glen Ridge Circle    |
|                                             Winston, GA           30187    |
|                                                                            | 
| Please allow 2 to 3 weeks for deliveries within the United States.         |
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