Pocket Diary Licensing Form
                      ---------------------------

  Name: ________________________________________________________
        (First Name, Middle Initial, Last Name)

  Company: _____________________________________________________
           (Required for Commercial License)

  Street Address: ______________________________________________

  City: ___________________  State / Province: _________________

  E-mail Address: ______________________________________________
                  (Info sent here; please write clearly)

  [ __ ]  Send me announcements for new versions of Pocket Diary

  Comments & Suggestions: ______________________________________

  ______________________________________________________________

  License Type: (Select One)

  [ __ ]    Non-profit Use   10 (US$) x [ _______ ] Computer(s)
  
  [ __ ]    Commercial Use   30 (US$) x [ _______ ] Computer(s)

  To make your donation and support the Pocket Diary project, 
  please make check or money order payable to Mario Mueller and
  send it to:

                         Mario L. Mueller
                        Attn: Pocket Diary
                         P.O. Box 230172
                       Las Vegas, NV 89123

  Please do *not* send cash. Your licensing information will be sent
  to the e-mail address you have specified above. Please allow time 
  for your form to be sent and any checks to clear. Thank you for 
  supporting the Pocket Diary project!