|
CONTACT INFORMATION please print clearly
Title___________________
Name___________________________________________
Address_________________________________________
Town____________________________________________
State_______________Postcode__ __ __ __
Phone__________________________________________
Email___________________________________________
PAYMENT
Cheque_____(payable to Trio Anima Mundi) or
Credit Card______________
Cardholder Name_________________________________
Type of card: Visa________Mastercard________
Card Number:__ __ __ __/ __ __ __ __/ __ __ __ __/
__ __ __ __ Expiry Date: __ __/ __ __
Verification No. (last 3 digits of number on the back of your card): __ __ __
Tickets Total $_________
Signature______________________________________
MAIL FORM TO:
TAM - Ticketing
55 Atkinson St., Ballan, 3342
|
