GuildBoss FAX Registration Form
[Please print clearly and do not forget to include your System ID (found on the GuildBoss About box)]

Number of copies to register _______ X $20.00 U.S. = _________________

Name ____________________________________________________________

Address 1 _________________________________________________________

Address 2 _________________________________________________________

City ______________________________________________________________

State/Province ______________________________________________________

Zip/Postal code _____________________________________________________

Country ___________________________________________________________

Phone ____________________________________________________________

Email _____________________________________________________________
[Free email (e.g. Yahoo, Hotmail, etc.) is NOT accepted]

System ID _________________________________________________________

Authorization:

Credit card type: [ ] Visa [ ] MasterCard [ ] American Express

Credit card #: _______________________________________________________

Expiration date: ______________________________________________________

Signature: __________________________________________________________

[ ] I authorize Qwerks to bill my credit card and I agree to pay the total amount according to my card issuer agreement.

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