FAX Registration Form

From

Name: _____________________________

Phone: _________________________

FAX: _________________________

To

Name:  PalmGear H.Q.

Phone: (817)640-6558

FAX:   (817)640-6614

RE: Flytrap registration

Please register me for Flytrap as follows:

HotSync username: _____________________________

Email address: ______________________________________

Please bill $10 to my credit card as follows:

Credit card: [ ] VISA, [ ] MasterCard, [ ] American Express

Credit card number: _____________________________

Expiration date: ____________

Name on credit card: _____________________________

Billing address: _________________________________________

                 _________________________________________

City: _____________________________

State: ___________________

ZIP: ___________________

Country: ___________________

----End of Form----