Balticon 34 Registration Form
                                
Name: ______________________________________    Adult  Child (circle one)

Badge Name: ___________________________________

Name: ______________________________________    Adult  Child (circle one)

Badge Name: ___________________________________

Name: ______________________________________    Adult  Child (circle one)

Badge Name: ___________________________________  

Name: ______________________________________    Adult  Child (circle one)

Badge Name: ___________________________________                          
     
Address: _______________________________________

________________________________________________
 
City:____________________State:______ZIP:_______  Country:_______________

e-mail:____________________________         Phone: (      )______________  

If postmarked by:  06/30/99  12/31/99  03/31/00  At the door  Number  Total

 Adult               $30       $35       $40        $45      x_____  $______
   
 Child (age 6-12)    $15       $18       $20        $23      x_____  $______

Balticon 34 Masquerade Video                        $21      x_____  $______

                                                               Total $______
Payment Options:

[ ] Check or Money Order made payable to Balticon 34
[ ] Credit card
    [ ] Mastercard       
    [ ] Visa

    Card Number: _____________________________   Exp (Month/Year) _________

    Signature of Cardholder: x__________________________________

    Cardholder name as it 
    appears on the card:  ______________________________________

    Card Billing Address: _______________________________________

                          _______________________________________
            
                    City: ____________________State:______ZIP:_______

                 Country: ____________________

Send this form and payment to:

Balticon 34 Registration
P.O. Box 686
Baltimore,MD 21203-0686

Notes: Children under 6 are free if accompanied by an adult at ALL times.

Mail-in Registration deadline is March 31 2000.

Please copy this page for additional registrations.   One address per form,
please.

For more information, check your areas of interest below.

[ ] Handicapped access     [ ] Party Registration
[ ] Artist Registration    [ ] Writer's Workshop
[ ] Gaming                 [ ] Young Writer's Contest
[ ] Masquerade             [ ] Skills Demonstration
[ ] Programming            [ ] Reading is Fundemental
[ ] Volunteering           [ ] Costuming Track/Wrkshop
[ ] Filk Contest
[ ] Poetry Trk/Workshop    [ ] Other: ______________