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The Southern Flames present Julie Ferguson
Reactive Glass
Lottery/Registration
Form
Sat& Sun April 25-26-2009
Name:
Address:
Telephone:
Alternate
Telephone (mobile):
Email Address:
Do you want to be on the waiting list if your name is not drawn for a class session (circle one)? yes no
Please print out, complete, then mail the completed form and your check in the amount of $220.00 (Members) or $245.00 ( Non Members) made payable to “Southern Flames” to:
Southern Flames
c/o Martha Fuerst
2679 Mercedes Drive NE
Atlanta, Georgia 30345-3974
NOTE: CHECKS AND FORMS MUST BE RECEIVED BY Friday, Feb 20 (if mailed to Martha).
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For Southern Flames Administrative Use Only Please do not fill in below
Received On _________ Check # __________
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