
                            MOLEZ REGISTRATION FORM

       Your full name: ________________________________ (max. 32 letters)
       This is the name the game will be registered to! (real names only)

       Date of birth: ________  Sex: ______


       !IMPORTANT!          Registration type:  Email [_] / SnailMail [_]

       Full mailing address                     Email address:
       ___________________________________      _________________________
       ___________________________________      (In email registration
       ___________________________________      the key is sent to this
       ___________________________________      address)

       Exclude my name from the list of registered users: [_] (The list may
       be included in molez archive and FRACTiLE home pages)

       Ammount of your donation: _________      

       Where did you get MoleZ:
       __________________________________________________________________
       __________________________________________________________________

       Some comments on the game:                              (optional)
       __________________________________________________________________
       __________________________________________________________________
       __________________________________________________________________
       __________________________________________________________________



       Date & Signature: ________________________________________________

