Scrapbook Weekend Retreat

_____________________(which retreat)

Registration Form

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

City:____________________________________State:_______________________ Zip:______________

Phone No.:_____________________________Alternate Phone # :________________________________

Email______________________________________________Roommate:__________________________

SELECT PAYMENT AMOUNT:

Deposit $50 due with application balance due 1st of month prior to event date ____________YES

Payment in full ________________________________________________________________

NOTE: Late fee of $25 added if deposit or payment not received by date specified on web

Crop Room (please list the names of people you wish to sit with; we will do our best to accommodate you)

Table Mates:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Payment Type:

Check – made payable to Mary Full: mail to 4140 Valencia Rd., Chesapeake VA 23321 (preferred payment type)

or Visa MasterCard Discover American Express

Credit Card Information: By completing the information below, you authorize Mary Full to charge the below card the amount specified.

Cardholder Name_______________________________________________________________________

Card No.:_____________________________________________Security code on back of card_________

Expiration Date:___________________________Zip Code:______________________________________

Signature:______________________________________________________________________________

How did you hear about us?

flyer friend Scrapbook Store Internet Email other

NOTE: A $35.00 return check fee will incur plus any related court fees for any reason a check is returned.

Mary Full

mertful@yahoo.com

757-287-4774