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 To return to the memberships page, click the "back" button on your browser.