Name: | ___________________________________________________ |
Street Address: | ___________________________________________________ |
City, State, Zip: | ___________________________________________________ |
Phone: | ______________________________________ |
Email: | ______________________________________ |
MIT Club of Southern California Member? | Yes _____ No_____ |
No. of Attendees: | _________________ |
Amount ($40/person for MIT Club members and their guests or $45/person for non-members and their guests) | $________________ |
Fax this registration form to (310) 798-7273 along with your MasterCard or Visa credit card number and expiration date. If the exact name on, and/or billing address for, the credit card is different than the name and/or address listed above, please provide the exact name and billing address as well:
MC__ VISA__ Card no.: ______-______-______-______ Exp. Date: ___/___
Exact name on and/or billing address for card, if different than the name and/or address provided above:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Or
VinoQuest
1601 N. Sepulveda Boulevard, #793
Manhattan Beach, CA 90266
There is a $5 refund processing fee per attendee; no refunds after February 17, 2004 unless you find someone to fill your spot.
Questions? Call VinoQuest at (310) 798-2004