World Fantasy Convention 2004 Membership Form


NAME(S) ____________________________________________________________________________________

ADDRESS ___________________________________________________________________________________

CITY ___________________________________ STATE/PROVINCE ___________________________________

ZIP/POSTAL CODE _____________________ COUNTRY ___________________________________________

EMAIL ____________________________________________________________________________________________

PHONE ___________________________________ FAX _____________________________________________

PROFESSION (Writer, Artist, Editor, Fan, etc.) ________________________________________________________

_____ Supporting Membership(s) at US$35.00 per membership = US$__________

_____ Attending Membership(s) at US$_____ per membership = US$__________

 Total US$__________

_____ Check:  We accept personal/business checks, cashiers checks or money orders for the total amount above.
Make it payable to WFC2004.

_____ Credit Card:  We accept Visa or Mastercard.  Charge may show Leprecon Inc. as recipient.  Leprecon Inc. is dba WFC2004.

Card Number __________________________________  ID CODE________ Expiration  _______________

Name As It Appears On Your Card (Please Print)  _____________________________________________________

Signature     ___________________________________________________________________________________

Mail to: WFC2004, c/o Leprecon Inc., P.O. Box 26665, Tempe, AZ 85285-6665 USA
 
 



 
 

Administered by Lee Whiteside