DALIA CARELLA
September 17, 2005
Mail-In Registration

Print & Mail to:
Marisa Pierson
2 Maryland Drive
Jackson, NJ 08527

732-905-0059

Workshop Registration:

How many for Workshop @ $65_________

Total Workshop Fee $_______________

Show Tickets:

Number of Show Tickets @ $20____________

Total Show Ticket Fee $_____________

***Early Bird Special: Workshop + Show only $75 (before Aug. 31)

Grand Total Classes & Show $____________

Make checks or money order payable to: Marisa Pierson
(VISA, Mastercard and Discover also accepted)

Card Number:______________________________________________

Expiration date: ____________________________

Signature: ___________________________________________________

*****

Name:________________________________________________________________

Address: ____________________________________________________________

City, State, Zip:_________________________________________

Phone: ____________________________

E-mail:_____________________________