=== REGISTRATION FORM ===

Please cut and paste this section into your favorite word processor and fill out 
& return to Gallifrey One!  (Note: use a FIXED WIDTH font such as Courier New to 
make it print properly!)  You can also print it directly from Internet Explorer,
Firefox, Safari, Opera or any other browser!

Note: Registration via PAY-PAL is now available!  Check the main page of the 
Gallifrey 2010 web space for details!


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GALLIFREY ONE: BLACKJACK 21  (GALLIFREY 2010)

QUICK REGISTRATION FORM
Please fill out and return with a check or money order to:
Gallifrey Conventions, P.O. Box 8022, Van Nuys, CA 91406.

Make check payable to GALLIFREY ONE.
US FUNDS ONLY please!

You may or may not receive a postcard confirmation.  Please do not be alarmed if
you don't.  Your name(s) will be noted on the membership list on the website, to
be updated starting late summer 2009.


Name(s): _______________________________________________________________

Badge Name(s): _________________________________________________________
(this is if you want a name other than your real one on badge!)

Address: _______________________________________________________________

City: _____________________________________________    State: __________

Zip: _____________ Phone: ______________________________________________

Email: _________________________________________________________________

Item                           Price          Number  Amount Enclosed 

Membership-full (to Dec 31/09) $65.00         ______  __________
Membership-full (to Jan 31/10) $70.00         ______  __________
Membership-full (Feb 1-door)   $75.00         (don't mail... buy on site)

Membership/Age 12-16 (full)    $35.00         ______  __________
Membership/Under Age 12        Free **        ______  n/a

Dealers Tables				 	    SOLD OUT
Art Show	                 			    Inquire via email

TOTAL ENCLOSED: _____________________________

** Note: children under age 12 are free only with paid adult admission and
must be accompanied at all times.  Please indicate any children registering
with you on this form by including their names and the appropriate number.


___ Yes, I wish to volunteer!  Please let me know about volunteering at
    the Gallifrey 2010 convention.


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