PAYMENT FORM

Name:______________________________________________________

e-mail address :___________________________________________

or

Street address :____________________________________________

____________________________________________________________

____________________________________________________________

Registration (see Costs)                           $_____________

Accomodation                                   $_____________

Dinner:

Number at $50 p.p. [  ]

Number at $40 (student rate) [  ]

Number of vegetarian [  ]                         $_____________

Blue Mountains Tour:

Number at $80 p.p. [  ]                           $_____________

Preferred day:   Wed Jul 8 [  ] Mon Jul 13 [  ]

TOTAL                                        $_____________

Paying by cheque [  ]      Please make cheque out to GSA98

Bankcard [  ]     Mastercard [  ]     Visa [  ]

Name on card :_____________________________________

Number :___________________________________________

Expiry date : ________________________