****************************************** ** ** ** ADAMcon XIII REGISTRATION FORM ** ** ** ****************************************** Make checks payable to "ADAMcon 13" in US funds and mail to: Richard F. Drushel 3353 Mayfield Road Cleveland Heights, OH 44118-1329 USA Questions? Contact Rich at: drushel@apk.net (best) (216) 368-4804 (days) (216) 397-0684 (evenings) NAME________________________________ SPOUSE_______________________________ ADDRESS_________________________________________ PHONE____________________ CITY_____________________ STATE/PROV_______________ ZIP/POSTAL CODE_______ CHILDREN: 1_____________________ AGE_____ 2_____________________ AGE_____ 3_____________________ AGE_____ 4_____________________ AGE_____ If traveling alone and wish to share a room, check here____ Enter name of person you wish to have as a roommate___________________ Do you wish to be in a non-smoking room? YES____ NO____ Do you want an ADAMcon XIII T-shirt? $10.00 ea. YES____ NO____ (circle size) S M L XL XXL XXXL (add $2.00 for XXXL) Are you bringing hardware to the convention? YES____ NO____ If yes, what hardware will you be bringing? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ___ Delegate @ $275.00 = _________ ___ Non-Delegate Spouse @ 200.00 = _________ ___ Non-Delegate Children @ 45.00 = _________ ___ Delegate Children @ 120.00 = _________ ___ Single Room @ 40.00 per night = _________ ___ T-Shirt @ 10.00 = _________ TOTAL _____________ DEPOSIT/PAID _____________ BALANCE DUE _____________