First Name:_________________________  Last Name:_____________________________

Mailing Address:  Street:____________________________________________ Apt. #:_____

City/Town:______________________________ State/Province:_______________________

Postal Code:_________________        E-Mail Address:______________________________

ICQ Number:___________________  Instant Messenger Handle:______________________
 

Method of Payment:  (Must be payable to Shannon Matteson, in U. S. dollars.)
    [  ] Cash (Not reccomended.)
    [  ] Check
    [  ] Money Order (Preferred.)

Amount of Payment: $_________  (Florida residents please add 6.5% sales tax.)

Payment is For:  [  ] Registration    Software Code:__________________________

                         [  ] Upgrade From Version _____ to Version _____

Please complete this order form, print it out and send it, with appropriate payment, to:

LottoWheeler 1.10.165 Registration
1182 SW Curtis St.
Port St. Lucie, FL 34983