Registration Form, Canadian Dollars

Rev. 17-Sep-2004

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L.A.con IV: Registration Form - Canadian Dollars                    20040914

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


Name _________________________________________________________________________


Address ______________________________________________________________________

                                                          
City ___________________________ Province __________ Postal Code _____________


Country _____________________________ E-mail _________________________________


__ Attending Membership .....................................   C$195

__ Child 5-12 ...............................................    C$70

__ Installment Plan, first payment (Supporting Membership) ..    C$70

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

__ Supporting Membership ....................................    C$70

__ Conversion: If you voted at TorCon 3 .....................   C$142

__ Conversion: If you purchased a Supporting Membership after   C$130
   TorCon 3 (for C$70)


Make cheques in Canadian funds payable to LLOYD PENNEY.

L.A.con IV, c/o
Lloyd and Yvonne Penney
1706 - 24 Eva Road, 
Etobicoke, ON M9C 2B2

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• Installment Plan
• Registration Form - US$
• Registration Form - UK Pounds or Euros

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