
   POVANI REGISTRATION FORM version 1.0
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   Name:_________________________________________________________________________

   Address:______________________________________________________________________

   City,State,zip code:__________________________________________________________

            E-mail   : __________________________________________________________


   Method of payment:

     Registration  fee per version (US$ 20.00)           

       [  ]  Credit card (only VISA, MASTER CARD, AMERICAN EXPRESS or DISCOVER CARD)
            
                 AMOUNT: US$_________________

            Card holder: _________________________________

            Card Number: _________________________________

            Expiration date: ____ / ____   [  ] VISA   [  ] MC   [  ] AX    [  ] DISCOVER

            Signature  : _________________________________

      
   ADDITIONAL COMMENTS:____________________________________________________________

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