Name:
|
Telephone:
|
Address:
|
City, State, Zip:
|
Email:
|
Organization Affiliation (if any):
|
Meals - Please
specify special nutritional requirements below:
|
I plan to arrive: [ ] Friday
evening [ ] Saturday
Other: |
I plan to stay at the Holiday Inn:
[ ] Yes [ ] No
(if yes, please make reservations through our Hotel Coordinator
HotelCoordinator,
HotelCoordinatorTelephone,
HotelEmail,
or use our Online Store) |
Roommates?:
|
Special Requirements:
|
|
Anniversary Anniversary
T-Shirts each
t-shirtprice
additional --
please indicate quantity: [ ] |
[ ]
Small [ ]
Medium [ ]
Large
[ ]
X-large [
] XX-large |
|
Total Remittance:
$ |
| Payment Method: |
[
] Check/Money Order
[ ] Visa [ ] Mastercard [ ] American
Express [ ]
Discover |
|
Account Number:
|
I hereby certify
that I am 21 years of age or older and that I will abide by all
rules and regulations pertaining to this event. I will not use
illegal drugs, perform illegal acts, or hold the LI Ravens MC, Inc.
or participating venues responsible for damages or personal injuries
to my personal property or self. This is a private event; the L.I.
Ravens M.C., Inc. reserves the right to refuse admission or eject
any person for any reason whatsoever. |
| Expiration Date
(mm/yy) |
Security Code:
(what's this) |
Name on card:
|
Your Signature:
|
