Your real name (First and Last name) __________________________________________

Location (City,State)__________________________________________________________________

Home Telephone, or other number where you can be reached _______________________

The following questions only apply to a dialup (modem) site:
          Modem (brand name/model) ___________________________________________
          BBS telephone number ________________________________________________

If you will also have an Internet node
or
If you will only be running an Internet node,  Answer the following:
 

Domain/IP Address _________________________________
Your e-mail address: _________________________________