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(For credit card payment confirmation to be forwarded)

This is a Tax Invoice. Please retain a copy for your records

We look forward celebrating our night with you

Registration Form & Tax Invoice

COMPANY:

NAME:

NAME:

Attach List if Insufficient Space

No. __________ X $____________ Total Cost

$____________

I enclose my cheque for $ payable to AICLA or

If you wish to pay by credit card please complete below:

Mastercard (please circle)

Visa Amex

Cardholders Name:

Card Number:

Expiry Date: Amount: $

Signature:

Email Address:

Forward Completed Form to: