THE VICTORIAN SOCIETY IN AMERICA HOOSIER CHAPTER

LAST DINNER ON THE TITANIC REGISTRATION FULL NAME ADDRESS

TELEPHONE

CITY, ST ZIP

PRIMARY EMAIL

REGISTRATION

COST PER TICKET

Hoosier Chapter Member

$55.00

Non-Member *Special offer : Become a member of the Hoosier Chapter at a discounted rate! (Current members may renew at this special rate.)

$70.00

NUMBER OF TICKETS

TOTAL

$20.00

TOTAL DUE

PAYMENT OPTIONS

PAY ONLINE Pay online with credit, debit, or instant transfer with PayPal. You will need a free PayPal account for this payment option. Visit http://www.paypal.com. Choose the “Send Money” tab and remit payment to [email protected]. CHECK or MONEY ORDER ENCLOSED

FOR V.S.A. Hoosier Chapter USE ONLY: Received ___ / ___ / ___ $__________________ PAID via Check# _______ M.O. PayPal Trans ID#_____________ Membership/Renewal Processed ___ / ___ / ___

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