First name: ____________________________________________________________ Middle initial: ______
Last name: ________________________________________________________________________________
Address: _________________________________________________________________________________
Address 2: ________________________________________________________________________________
City: ___________________________________________ State: _______ Zip: ________________________
Home phone: _________________________________Work phone: _________________________________
Email address: _____________________________________________________________________________
Number of adult tickets: ________ Number of child (age 2 through 12) tickets: ________
Cost of adult tickets $25.00 Cost of child tickets: $12.00 Total:
Please indicate next to acceptable times “1” for first choice, “2” for second choice, etc. We will fill the order based on this information, going in order of preference. If we are unable to fill your order following your order of preference, your order and payment will be returned to you.
_____October 10th at 9:30 am _____October 10th at 1:30 pm
_____October 17th at 9:30 am _____October 17th at 1:30 pm
_____October 24th at 9:30 am _____October 24th at 1:30 pm
Payment Method: ÿ VISA ÿ MasterCard ÿ Check # ______ (Payable to: Old Dominion Chapter, NRHS)
Credit card account number: _______________________________________Exp Date(mm/yyyy):__________
Cardholder name if different: _____________________________________CCV #_______________________
Cardholder Billing Address if different: _________________________________________________________
Cardholder signature: _______________________________________________________________________
Please print this form and send to:
Old Dominion Chapter, NRHS
Attn: Excursion Ticket Sales
P O Box 1323
COLONIAL HEIGHTS VA 23834.