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Registration Information

Checks or credit cards (Mastercard, Visa or American Express only) accepted. Make checks out to "ASIST/PVC." Completed registration forms may be mailed or faxed to Jon Simons at:

FAX/MAIL IN - REGISTRATION FORM -
International Bazaar and Merrymaking, May 15, 2003

Name ___________________________________________________

Phone ___________________ E-Mail __________________________

Payment by Check   Visa/MC/American Express (please circle one)
Amount:*     $8.00  or  $10.00 (after May 9th) 
Donation: ______ Please make checks payable to: "ASIST/PVC"
TOTAL:  ______

Card Number _____________________________ Expiration ___/___

Name on Card _____________________________________________
(Please Print)

Signature _________________________________________________