7/11 application form

By Griff
January 17 2005

Please reserve me ___ tickets for the LISC-7/11 event at the Millennium Madejski Hotel, Reading on the 4th February 2005.

Name :

Address :

Postcode :

Contact telephone number:

I wish to pay by cheque/credit card^* (delete as applicable)

Make cheques payable to LISC

Please debit my Credit/Debit card.

Number:

Expiry:

/

Signature :

Please send this form along with chosen payment method to:

LISC (7/11),
The Three Horseshoes,
Hazel End,
Farnham,
Essex,
CM23 1HB