iCONIFW 2007 MSP Registration Form

iCONIFW 2007 MSP

Registration Form

Please complete one form for each person registering for iCONIFW 2007 MSP. You can submit the payment for the registration by PayPal or by printing this form and sending it, along with the appropriate payment, to the address shown below. Any questions regarding the registration can be directed to: iconifw2007@lycminnesota.org.

Please provide the following contact information:

Full Name:

Nickname (for name badge):

Mailing Address:

City:

State/Province:

Zip/Postal Code:

Country:

E-Mail Address:

Telephone:

Cellular Telephone:

Dietary Needs (vegetarian):

Please indicate your group affiliation. We are collecting this information for demographic purposes.

LYC
IFA
Other

Please indicate the size of t-shirt you will need:

Small
Medium
Large
X-Large
XX-Large
XXX-Large

Select your registration amount based on the dates shown below:

$235.00 - postmarked or paid online before 4/30/2007
$260.00 - postmarked or paid online after 5/1/2007

Registration form can be mailed, along with appropriate payment, to:

iCONIFW 2007 MSP
c/o Rick Simon
1101 Wes 28th Street, Apt. 303
Minneapolis, MN 55408

*Full Name:*
*Nickname (for name badge):*
*Mailing Address:*
*City:*
*State/Province:*
*Zip/Postal Code:*
*Country:*
*E-Mail Address:*
*Telephone:*
*Cellular Telephone:*
*Dietary Needs (vegetarian):*

Prepared by Rick Simon. Back to Information PageCopyright © 2006 [Long Yang Club Minnesota]. All rights reserved. Revised: 03/22/07

Prepared by Rick Simon. Back to Information Page
Copyright © 2006 [Long Yang Club Minnesota]. All rights reserved.
Revised: 03/22/07