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UWR Request Form

Fax Numbers ==>

Netherlands

+31-20 524-1309

USA

+1-212-656-1408

Please register me as an UWR Member for the coming year (‘98-'99) and send me the tickets as indicated below. I understand that my tickets will be forwarded to me within one month of receipt by UWR of cleared funds, and a fully completed Application form.

The following information regarding the purchase of Tickets, at each level, applies to all Members

Your First purchase is restricted to a maximum of 25 Tickets (£625/US$1000)

Your Second purchase is restricted to a maximum of 75 Tickets (£1875/US$3000)

Your Third purchase is restricted to a maximum of 125 Tickets (£3125/US$5000)

After your third System entry, you will be eligible to purchasing up to a maximum of 125 Tickets at a time.

My First Purchase

     

I would like to purchase

 

Tickets (max 25)@ £25/US$40 each

 

My Second Purchase

     

I would like to purchase

 

Tickets (max 75)@ £25/US$40 each

 

My Third Purchase

     

I would like to purchase

 

Tickets (max 125)@ £25/US$40 each

 

I am eligible to purchase

a maximum

of 125 Tickets

 

I would like to purchase

 

Tickets (max 125)@ £25/US$40 each

 

I enclose my annual Membership Fee of £10/US $20 (all new Members must pay the Membership Fee on first entry)

 

I enclose payment for my UWR ATM Card, to qualify for the discount price of only £52/US$80

 

From the above order I would like to roll over

 

Tickets

and claim payment for

 

Tickets

TOTAL PAYMENT ENCLOSED

 

Unfortunately UWR can only accept payments in £Pounds Sterling or $US Dollars

Personal Details

Surname

 

First Name

 

Address

 

   
 

 

   

City/Town

 

State/County

 

Post Code

 

Country

 

Tel. No

 

Fax No

 

Email

 

   

Signature

 

Date

 

Sponsors Name

 

   

Yes, I would like to participate in the additional Prize Draws, please send me further details.