Registration Form
ICON 30 REGISTRATION FORM
OCTOBER 28 – 30, 2005: CLARION ZAZZA, CEDAR RAPIDS, IA
(Rates listed below are good until 10/15/2005)
Mailing Address: ICON, 308 E. Burlington PMB#201, Iowa City, IA 52240
NAME: __________________________________________________________
ADDRESS: _______________________________________________________
PHONE NUMBER: _________________________________________________
EMAIL ADDRESS: ________________________________________________
BADGE NAME: ___________________________________________________
I WILL BE 21 AS OF 10/28/2005: YES / NO
REGISTRATION TYPE:
(PLEASE SELECT ONE PER REGISTRATION FORM)
_____ BENEFACTOR: $100.00
_____ SPONSOR: $60.00
_____ ENTERTAINMENT:$15.00
ADULT / CHILD
_____ WEEKEND: $35.00 / $20.00
_____ FRIDAY: $20.00 / $10.00
_____ SATURDAY: $25.00 / $15.00
_____ SUNDAY: $10.00 / $7.00
T-SHIRT: S - M - L - XL - XXL - XXXL
COST: $15.00 PER SHIRT NUMBER OF SHIRTS: _____