Virginia Scrapbook Retreats

Application

1. 
   Application

   Scrapbook Weekend Retreat Registration Form PRINT & RETURN by mail _____________________________________(which retreat) Name:_________________________________________________________________________________________ Address:_______________________________________________________________________________________ City:____________________________________State:_______________________ Zip:________________________ Phone No.:_____________________________Alternate Phone # :__________________________________________ Email______________________________________________Roommate:____________________________________ SELECT PAYMENT AMOUNT: Deposit $50 due with application balance due 1st of month prior to event date as specified on Retreat site____________YES Payment in full ___________________________________________________________________________________ NOTE: Late fee of $25 added if deposit or payment not received by date specified on web Crop Room (please list the names of people you wish to sit with; we will do our best to accommodate you) Table Mates: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Payment Type:  Check – made payable to Mary Full: mail to 4140 Valencia Rd., Chesapeake VA 23321 (preferred payment type) or Visa MasterCard Discover American Express Credit Card Information: By completing the information below, you authorize Mary Full to charge the below card the amount specified. Cardholder Name_______________________________________________________________________ Card No.:_____________________________________________Security code on back of card_________ Expiration Date:___________________________Zip Code:______________________________________ Signature:______________________________________________________________________________ How did you hear about us? flyer friend Scrapbook Store Internet Email other NOTE: A $35.00 return check fee will incur plus any related court fees for any reason a check is returned. Mary Full mertful@yahoo.com 757-287-4774 PLEASE PRINT AND MAIL THIS FORM BACK TO ME 4140 Valencia Rd. Chesapeake VA 23321

   http://www.virginiascrapbookretreats.com/documents/Online%20Scrapbook%20Retreat%20Application.pdf
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