Name (first, middle initial, and last name, as shown on your credit card): *
Street address: *
City: *
State or province: *
ZIP or postal code:*
Country: *
Telephone number: (home) (work)
Email address:
Type of card: * Visa Mastercard
Card number: *
Expiration date: *
QTY Adult memberships (@$45): $ No advance memberships will be accepted after 9/26/2003; memberships may still be purchased for $45 at the door Young Adults (ages 11-16 @$20): $ Children (ages 6-10 @$8): $ Infants (under 6 @FREE): $ Friday Dinner Theater Banquet Adults (@$20): $ Children ages 1-10 (@$10): $ FULL NAME BADGE NAME (if different) Member #1: * AGE (your age on the first day of the convention; if age is not given, an under-21 badge will be issued) Member #2: AGE Member #3: AGE Member #4: AGE Member #5: AGE Member #6: AGE
MEMBERSHIP TOTAL $
TOTAL ORDER $
QTY Size Small @$15: $ Size Medium @$15: $ Size Large @$15: $ Size XL @$15: $ Size 2XL @$15: $ Size 3XL @$15: $ Size 5XLT @$20: $
QTY Archon 13 Poster (@$6): $ ONLY 5 LEFT
QTY Archon 20 Pin (@$2): $ Archon 21 Pin (@$2): $ Archon 22 Pin (@$2): $ (Archon 22 members get one free at Archon 23 or subsequent Archons) Archon 23 Pin (@$2): $ Archon 24 Pin SOLD OUT Archon 25 Pin (@$2): $ Archon 26 Pin (@$2): $
QTY Covers (@$2): $
MERCHANDISE TOTAL $
Please send information on: ART SHOW ROBO WARS DEALERS ROOM MINIATURES CONTEST CHILDREN'S PROGRAMMING MODELING CONTEST CHILDREN'S MASQUERADE WRITERS WORKSHOP MASQUERADE CONTEST GAMING VIDEO FESTIVAL VOLUNTEERING
Comments (optional):
MEMBERSHIP TOTAL $ MERCHANDISE TOTAL $