Send $10 per certificate to

                          Mark Jason Dominus
                        255 South Warnock St.
                        Philadelphia PA 19107

Your name as you want it to appear on the certificate: 



______________________________________________________________________


Your title:   (optional)



______________________________________________________________________
(Default: Certified Perl Programmer)


Date:  (optional)



_________________________________________
(Default: The real date, in the format "1 April 2001")



Certificate number:   (optional)



_________________________________________
(Default: "#500601", until the release of Perl 5.8.0, when it will be
"#500800".) 


Your email address:



______________________________________________________
(This is mostly so I can contact you if you ask for text that doesn't fit.)



Do you want me to send you email in the future about other
certificate-related news?  (I expect to send at most one or two
messages total, probably less.)

+----+                         +----+
|    |  No                     |    |  Yes
|    |  (default)              |    |
+----+                         +----+ 


Your shipping address: