Online Payment for the 2009 Retreat

*** Use this form only if you plan to pay by a Credit Card or PayPal ***

Please fill in the information below for our records.

Information you provide will never be given to any other organization or group at any time. We will only use this information to inform you about the retreat or other GMSR events.

  Name on the Credit Card
   or PayPal Account
   you plan to use:

  First Name

  Last Name

  Address

  Address

  City

  State

  Zip Code

  Phone

  EMail

May we use email for correspondence with you? Yes No

What would you like printed on your name tag?

Leave us a message below if you wish

Name on the Credit Card or PayPal Account you plan to use:

First Name
Last Name
Address
Address
City
State
Zip Code
Phone
EMail

May we use email for correspondence with you?	Yes No
What would you like printed on your name tag?
Leave us a message below if you wish