|
Date:
|
_________________________________ |
|
Name:
|
________________________________________________________ |
|
Address:
|
_________________________________________________________________________________ _________________________________________________________________________________ |
|
City:
|
___________________________ |
|
State:
|
________________ |
|
Zip:
|
_____________ |
|
Country:
|
______________________ |
|
Phone:
|
__________________________ |
|
Email
address:
|
_____________________________________ |
If you are using a credit card for payment, and the billing name or address for the card is different from the one you gave above, please print the billing name and address below:
Carefully print the names and menu choices of all ticket holders. (Meat, fish, or vegetarian. Names are needed for name tags.)
Payment information:
| _____ |
Number of "Full-weekend" tickets you are ordering ($80 each; includes all programming, parties, and the Stoker Awards banquet.) |
| _____ |
Number of "Parties/panels only" tickets you are ordering ($50 each; does not include Stoker Awards banquet.) |
| _____ |
Total payment amount |
|
Credit
card type:
|
___ Visa ___ MC ___ Amex |
|
Card
number:
|
_______________________________ |
|
Expiration
date:
|
_______ / _____________ |
|
CVV2
number*:
|
________________ |
|
Signature:
|
_______________________________ |
*Your CVV2 number is a 3- or 4-digit number used for additional security in online transactions. On Visa/MasterCard cards, the verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. The American Express verification number is a small 4-digit number printed on the front of your card on the right hand side. If you can't find your CVV2 number, please contact us at treasurer@horror.org.
Print this form, fill it out, and mail it with your check (payable to Horror Writers Association), money order, or credit card instructions to:
Lisa Morton
Horror Writers Association
5022 Riverton St. #9
N. Hollywood, CA 91601
U.S.A.
CHECKS AND MONEY ORDERS MUST BE DRAWN IN U.S. DOLLARS. PAYMENT MUST BE RECEIVED BY JUNE 9, 2006.