                  Ŀ
                  Split Screen Chat Registration Form
                  


 Name:                               DO NOT
         EXCEED!
       (print it as you want it to be seen on your registration)


Address: ________________________________________________________________

         ________________________________________________________________

Country: _____________________________     Postal Code: _________________

Tel.   : ____________________________     Tel.  : _______________________
(Home)                                     (Bus.)


     Enclosed within is $____________ in ____________ currency in 

______________________ form.
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