Registration form for e-Daily Assistant

Program No.: 183171

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
• fax
• postal mail

How would you like to pay the registration fee of $25:

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 _____________________________