LOSCON 34 Registration Form
RATES:
$50 Adult
$25 Child (4-12)
Make checks payable to LOSCON 34.
Send your check and the following information to:
LOSCON 34
C/O Los Angeles Science Fantasy Society
11513 Burbank Blvd.
North Hollywood, CA 91601
Name:____________________________________________________________
Badge Name (Optional):____________________________________________
Address:__________________________________________________________
City:______________________________ State:________ Zip:______________
Country (If not United States):______________________________________
Phone:______________________ Email (Optional):______________________
OK to list name online? Y ( ) N ( )
Quantity: ______
Amount: ______
Total: ______
Webform 12/06 |  |