Memberships Registration Form, Australian Dollars

Rev. 15-Sep-2005

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L.A.con IV: Registration Form - Australian Dollars                    20050913

                                 L.A.con IV
                             23-27 August 2006
                            Anaheim, California


Name _________________________________________________________________________


Address ______________________________________________________________________

                                                          
City ___________________________ State _______________ Post Code _____________


Country _____________________________ E-mail _________________________________


__ Attending Membership .....................................   A$225

__ Child 5-11 ...............................................    A$65
   born on or after 23-Aug-1994, and on or before 22-Aug-2001

__ Installment Plan, first payment (Supporting Membership) ..    A$65

__ Installment plan payment .................................   _____

__ Supporting Membership ....................................    A$65

__ For other membership rates, please send e-mail to membership@laconiv.org


Make cheques in Australian funds payable to EDWIN SCRIBNER.
L.A.con IV, c/o
Edwin Scribner
12 Richmount St
Cronulla NSW 2230
Australia

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