Registration Form

(Please Print)                          Mrs.____ Mr.____ Ms.____ Other____

Name(1) _________________________________________________

          (2) _________________________________________________ 

         (3) _________________________________________________

         (4) _________________________________________________

Address __________________________________________________

City _____________________ State ________ Zip _______________

Phone ___________________ E-mail __________________________

1~Membership # _________ Chapter __________________________

2~Membership # _________ Chapter __________________________

3~Membership # _________ Chapter __________________________

4~Membership # _________ Chapter __________________________

______ x $300.00 = (US)$ ______________

Please make checks/money orders payable to:
Columbia Chapter, BCIS ~ Convention Account



Signed: .................................................................................................


                                                          Date: ..........................................

Please mail signed and dated registration form
with your check or Money Order (US$) to:

Pat Holm, Coordinator
2320 S.E. Spyglass Drive
Vancouver,  WA    98683
U.S.A.

For additional information, call or E-mail Pat at:
(360) 892 2917    E-mail <holmmark@aol.com>