Keycon 2000 Membership Registration Form

Name: __________________________________________________________________

Address: _______________________________________________________________

City: _________________________ Province/State: ________________________

Postal/Zip Code: __________________ Country: ___________________________

E-mail Address: ________________________________________________________

Phone Number: (_________)_______________________________________________

Date of Birth: _____/_____/_____ Male: _____  Female: _____

Cheque _____ Money Order _____ Visa _____ Mastercard _____

Credit Card Number: ___________________________ Exp. Date: _____ / _____

Badge Name: ____________________________________________________________

Signature: _____________________________________________________________

To purchase your membership, just print out this form,
and mail with your payment (cheque, money order, Mastercard or Visa,
please) to:

Keycon 2000
P.O. Box 3178
Winnipeg, MB R3C 4E6
CANADA

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