REGISTRATION FORM

FIRST AID 
Disk # 4082

Complete and mail today.
REGISTRATION FEE: $10.00

Mail with payment to:

MARKETING SERVICES CORPORATION OF AMERICA
3157 MADISON STREET    WAUKESHA, WI 53188

NAME____________________________________________________

ADDRESS_________________________________________________

CITY_____________________STATE____________ZIP___________

TELEPHONE (with area code) _______    __________________

[ ] PAYMENT ENCLOSED    AMOUNT $_____________

CHARGE TO   [ ] VISA   [ ] MASTERCARD

CARD NUMBER ___________________________EXPIRES__________

CARDHOLDER'S NAME_______________________________________

SIGNATURE [required]____________________________________