ICGA/HOACGA Mega2Convention Registration Form (ICGA Version)

Name*

First NameLast Name

Spouse

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Convention Registration @$25 each

Wednesday Night Hwy 63 Diner (Number Attending @Pay on Your Own)

Thursday Night Welcome Reception Pizza Party (Number Attending)

Friday Lunch Buffet (Number Attending @$25 each)

Friday Evening Banquet (Number Attending @$40 each)

Special diet meal needed (diabetic, vegetarian, etc.)

Saturday Lunch Sandwich Buffet (Number Attending @$20 each)

Receptions Donation ($)

Donating A White Elephant Auction Item?

YesNo

Bringing a Room Display? Reserve One 6' Table in the Common Room

YesNo

Selling Glass in the Common Room? Reserve 6' Table in the Common Room (Limit 2 @$15 each)

One - $15Two - $30

ICGA Annual Dues (Join or Renewal, not required for registration)

Electronic Newsletter - $15Print/Mail Newsletter - $50

Total:

In US Dollars

Please verify that you are human*