In order to register you must supply |
Register by December 31, 2006 and be
eligible for special drawing!
March 1, 2007 is deadline for registration.
___________________________________
First Name
Last Name
(1) ______________________________________________
(2) ______________________________________________
(3) ______________________________________________
(4) ______________________________________________
Address : ________________________________________
_________________________________________________
City : ____________________________________________
State : ___________________________________________
Zip Code/ Country Code : ___________________________
Phone Number : __________________________________
Email : ___________________________________________
______ x $325.00 US Dollars:/ £185.00 (circle one)
Make Check or Money Order payable to :
BCIS Convention 2007
(circle one) VISA
MASTERCARD
Acct. Number : ___________________________________
Name on Card : ___________________________________
Expiration Date : __________________________________
Signature : _______________________________________
Mail to : BCIS
P.O. Box 1498
Great Falls, VA 22066
USA
E-Mail:
info@belleek.com