Name:__________________________________________________________________
Address: ________________________________________________________________
City: __________________________________ State__________ Postal Code________
Country: ______________________________ District:__________________________
Phone number: _____________________ E-mail Address: _______________________
Credit Card Type: MasterCard, Visa, AMEX
Credit Card Number:______________________________________________
Expiration Date:________________________________
Will you be picking your ticket up at the International Convention? qYes qNo
Please return forms to: Optimist International, Attn: CCC 4494 Lindell Blvd. St Louis, MO 63108 or via fax at (314) 371-6006 by June 16th! |