Registration form for Capture Screen Studio

Program No.: 162224

Last name: _______________________________________________

First name: ______________________________________________

Company: _________________________________________________

Street and #: ____________________________________________

City, State, postal code: ________________________________

Country: _________________________________________________

Phone: ___________________________________________________

Fax: _____________________________________________________

E-Mail: __________________________________________________

How would like to receive the registration key/full version?

e-mail.

How would you like to pay the registration fee:

credit card - wire transfer - EuroCheque - cash

Credit card information (if applicable)

Credit card: Visa - Eurocard/Mastercard - American Express - Diners Club

Card holder: _____________________________________________

Card No.: ________________________________________________

Date of Expiration : _____________________________________

Date / Signature _________________________________________