Registration

Print and Fax in

Name:
Company Name:
Address:

City:
Province:
Postal Code:
Home Phone:
Business Phone:
Fax:
E-mail:
Occupation:
Employer:
Goals:	Please type a synopsis of your goal here.
	This information will be distributed amongst participants

Become a member of Women in Film and Video Vancouver and get $75.00 off the cost of FLASH FORWARD!

	By January 6, 1999	After January 6, 1999
Member	$200.00	$270.00
Non-Memeber	$275.00	$345.00
Flash Forward Alumni	$150.00	$220.00

(A $75.00 non-refundable deposit is required to guarantee space.)
(No exceptions to the deadlines.)

Payment Method

Cash
Cheque
Visa
Card Number:
Experation Date:
Name on card:

Mail non-credit card type payments to:

Women in Film & Video Vancouver
1431 Howe Street
Vancouver, BC
V6Z 1R9

New Member

Yes

Full Payment must be received at the WIFVV office no later than January 28, 1999. Upon receipt of full payment you will receive a course package and assignment which you will be required to complete by the first day of the course.