Name (First and Last):
(If
you are paying for more than one person, please fill out a
separate form for each attendee. Thanks!) |
| Mailing Address:
(include apartment numbers or suite numbers)
|
| City:
|
State:
|
| Zip/PostalCode:
|
Country:
|
| Home Telephone (w/ area code):
|
| Cell Phone Number:
|
| Work Telephone (w/ area code):
|
Email Address:
IMPORTANT!
|
Dietary Choice:
Special Dietary Information (we will accomodate
special diet within reason) :
|
ROOMING (check one):
Double Occupancy OK
Roommate Name (if known):
|
Single Room ($300 extra)
(availability
on limited basis) |
| Smoker: No
Yes
|
TRAVEL: Flying
Driving
Shuttle: Yes
No
|
If flying, we need your travel
itinerary in detail when known. Please call, fax or email
your information. |
| Payment Method:
(Discover
is preferred if you have one!) |
| Authorized Amount:
|
| Credit Card Number:
Expiration Date:
|
Does your credit card statement mail to the
address supplied above?
Yes
No
.
If no, please supply statement billing address:
|
| How did you learn about Eupsychia?
|
| ADDITIONAL COMMENTS OR YOUR FLIGHT
INFORMATION:
(Airline Carrier, Departure City, Flight Numbers, Connecting
City and Flight Number, and Departure time on March 4th):
Do you need a response to your comment?
(If
yes, please make sure you give us your email address and
phone number in the appropriate fields above.) |
| By
pressing the "send" button, you are authorizing
Eupsychia, Inc. to charge your Credit Card the amount you
have indicated above...
|
|
•••••
THANKS!
WE LOOK FORWARD TO BEING WITH YOU THIS FEBRUARY!
|
