Print this form, fill it out, and send it with a check, money order, or charge card information to:

LepreCon 31
PO Box 26665
Tempe, AZ 85285

NAME(S) _____________________________________________________________

BADGE NAME(S)_______________________________________________________

ADDRESS ____________________________________________________________

CITY _________________________________________________________________

STATE/PROVINCE _____________________________________________________

ZIP/POSTAL CODE _____________________________________________________

EMAIL ________________________________________________________________

PHONE _______________________________________________________________

_______ Full (13 and older) Membership(s) at $_______ each = $_________

_______ Half (7-12) Membership(s) at $_______ each = $_________

Total $__________

_______ Check: We accept travelers checks, personal checks, business checks, cashiers checks or
money orders for the total amount above. Make it payable to LepreCon 31.

_______ Credit Card: We accept Visa, Mastercard, Discover or American Express. Charge may show
Leprecon Inc. as recipient. Leprecon Inc. is dba LepreCon 31.

Card Number ____________________________________________________________

3 or 4 digit auth code ____________ Expiration _______________________________

_________________________________________________________________________
Name as it appears on your card (please print)

_________________________________________________________________________
Signature