
 Dead Ansi Society Application                        Please PRINT or TYPE
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 Full Name :  _________________________________  Alias: __________________

 Mailing Information                      BBS Information (If Have One)
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 Address:  ________________________   |   Name: __________________________
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 City:     ________________________   |   BBS Phone: (____) ____ - _______
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 State:    ________________________   |   Hours: ___________   BPS: ______
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 Zip Code: ______________             |   Software: ______________________
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 Phone Number: (____) ____ - ______   |   Version: ____   Registered? ____
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 =====================================|   Nodes: ____   Years Online: ____
  TBRGuest Account @ 812-424-3781     |
  Name : GUEST    Password : GUEST    |
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  I would help out the group because...

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  _______________________________________________________________________
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                                               X ________________________   
                                                 (SIG)
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               Mail to:
                          DaS_App : Matthew Elzer
                              639 Reis Avenue
                            Evansville IN, 47711

                     (With Disk of Work You Have Done!)
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