Helicon II,
29 March - 1 April 2002 in St Helier, Jersey nr______________
Firstname: _______________________________
Lastname: ___________________________________
Street:
________________________________________________ Nationality: _______________
City/State:
________________________________________________ Birthdate: ___/___/___ d/m/y
Postal code:
________________ Country: _____________________________________ Male / Female
Email:
_____________________________________________________________________________
Badge name:
_____________________________________________________________________________
Membership: supp / att ( 0 – 5 / 6 - 11 / 12
- 17 / > 17) ________________ =
_____.___
Membership: supp / att ( 0 – 5 / 6 - 11 / 12
- 17 / > 17) ________________ =
_____.___
Currency: EUR / GBP / USD / _________________________________________
TOTAL = _____.___
For convention purpose only
Received on: ____/_______/_________ At:
_________________________________________________
Paid with: Cash /
IMO / Cred card / Giro / cheque + nr
________________________________
To cash by:
______________________________ Handled by : ______________ at: ______________
This info will be held in a database for the convention
purpose only.