MILLENNICON: 29 REGISTRATION FORM
PLEASE PRINT LEGIBLY
Complete form and send form and check made out to Millennicon (no cash please) to
Millennicon Registration
PMB-122
5818 Wilmington Pike
Centerville, Ohio  45459

$40 Until Feb. 28, 2015     $45 At The Door     
Children 5 and under...Free     Children 6-11...$10      
Children 12 and over...Full Price      

Memberships are non-transferable		
	

NAME: ____________________________________________________


ADDRESS: _________________________________________________


CITY: ____________________________________________________


STATE: _______________    ZIP CODE +4: ___________________


TELEPHONE: _________________  E-MAIL: ____________________


BADGE NAME: ____________________________________________  AMOUNT: __________


ADDITIONAL REGISTRATIONS

NAME: ____________________   BADGE NAME: _______________  AMOUNT: __________ 

NAME: ____________________   BADGE NAME: _______________  AMOUNT: __________ 

NAME: ____________________   BADGE NAME: _______________  AMOUNT: __________ 

NAME: ____________________   BADGE NAME: _______________  AMOUNT: __________ 

GAMERS PASS: ______________________________________       AMOUNT: __________
(Gamers Pass is good for Gaming, Dealers Room and Art Show ONLY)

                                                           TOTAL: __________

MILLENNICON USE ONLY

COMP:     FRIDAY:     SATURDAY:      SUNDAY:      FULL:      GAMERS:   

DATE RECEIVED: _________________     CHECK PAYMENT: _________________

TOTAL MEMBERSHIPS:  ____________     CHECK NUMBER: __________________

CASH PAYMENT: __________________     DATE RECEIVED: _________________