Wonderful World of Agates Registration Form

Registration Deadline April 1, 2008. Registration after April 1: $90

 

Name:  ____________________________________________________________________________

Address:  __________________________________________________________________________

City:  ____________________  State:  _________ Country:  __________PostCode:  ____________

Phone:  _____________________________               Fax:  _________________________________

E-Mail: ____________________________________________________________________________

Number of registrations _____  (@ $75 each/$90 each after 4/1) Total registrations $____________

Number of dinner banquet tickets*:          ____ (@$18.00 each)     total banquet        $___________

*There are no more banquet tickets available.

Grand Total                                                                                                      $___________

Payment Information: Check/Money order encloed (U.S. funds only)
                                   
                                                Credit Card (please circle):  VISA      Mastercard

Card Number:  ________ - _______ - ________  Exp. Date (mm/yy):  _______________

Signature: _______________________________________________________________

 

Registration Space is Limited
Don’t be disappointed — Register Early!!!

Please send this registration form with payment to:

Agates
Weis Earth Science Museum
University of Wisconsin-Fox Valley
1478 Midway Road
Menasha, Wisconsin 54952 USA

For information or questions:
Website:  www.agateshow2008.com
E-Mail:  agates2008@gmail.com
Phone: 1.920.832.2925 (Country Code: 011)