Registration Form, UK Pounds

Rev. 04-Jan-2004

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Plain text version of this form available

L.A.con IV: Registration Form - UK Pounds                           20040103

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


Name _________________________________________________________________________


Address ______________________________________________________________________

                                                          Zip/Post
City ________________________________ State/Prov__________  Code _____________


Country______________________________ E-mail _________________________________


__ Attending Membership ......................................   72 UK Pounds

__ Installment Plan, first payment (Supporting Membership) ...   30 UK Pounds

__ Installment plan payment ..................................  ______________

__ Supporting Membership .....................................   30 UK Pounds

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


Euro cheques should be made payable to John Harold. 
Send to: 
L.A.con IV
c/o John Harold, Robbie Bourget
8 Warren Close, Langley Slough, Berkshire UK SL3 7UA

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