ADAMcon VIII REGISTRATION FORM 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 VIII T-shirt? $10.00 ea. YES____ NO____ (circle size) M L XL XXL XXXL Do you want an ADAMcon VIII hat? $8.00 ea. YES____ NO____ Do you want an ADAMcon VIII cup? $4.50 ea. YES____ NO____ Are you bringing hardware to the convention? YES____ NO____ If yes, what hardware will you be bringing? __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ ___ Delegate @ $260.00 = _________ ___ Spouse @ 190.00 = _________ ___ Children @ 50.00 = _________ ___ Delegate children @ 110.00 = _________ Day Pass (see Fee Schedule for combinations with/without meals) _____ Friday = _________ _____ Saturday = _________ _____ Sunday = _________ ___ Single room @ 40.00 per night = _________ ___ T-Shirt @ 10.00 = _________ ___ Hat @ 8.00 = _________ ___ Cup @ 4.50 = _________ TOTAL _____________ DEPOSIT/PAID _____________ BALANCE DUE _____________ Make checks payable to: "ADAMcon VIII" in U.S. funds and send to either chairman. George M. Koczwara Herman L. Mason, Jr. 4034 E. 52nd St. 8912 Blaine Ave. Newburgh Hts., Oh 44105 Cleveland, Oh 44106