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