Marie Curie 1972: 2004 Birthday Celebration Registration Form

If you're planning to attend the 2004 50th Birthday Celebration, please complete this form and submit this form and mail payment by March 15, 2004. The information you provide here is kept strictly confidential (see our Privacy Policy). Fields marked with a * are required; all other fields are optional.

*Name:
	(Last, first)

Spouse's name:
	(Last, first)

Birthday month & day:
	(mm/dd)

Street address:
City:
State or Province:
Zip or postal code:
Country:

Phone:

*Email address:

*Number of attendees:
*Payment type:	Check Cash Money Order (in US dollars)
*Payment details:	Total: $ US Check number: (if applicable)

Fee information:	Event cost is $60.00 US per person, which includes lunch at the beach and dinner gala. Payment must be cash, check or money order, payable in US dollars only. Submission deadline: March 15, 2004. Please make checks payable to: Juliette Dang 11 Calle Escalon Camarillo, CA 93010