Capricon 25 - Mad Scientists

Dealer Form

Please print out this form and mail in along with payment to
Capricon 25 PO Box 60085 Chicago, IL 60660.
.

Company Name____________________________________________

Your Name________________________________________________

Address__________________________________________________

City________________________State_______Zip___________

Day Phone (___)__________ Evening Phone(___)____________

e-mail____________________________________________________

Additional Memberships
Name 1___________________________________________________

Name 2___________________________________________________

Name 3___________________________________________________

What do you sell?__________________________________________

Any additional info?___________________________________________

[ ] I would like a link to my web page from the Capricon 25 web site
URL________________________________________________________

One Table/One Membership $95.00................................____________

Additional Table/s @ $35.00 ea., limit 3 total..................____________

Additional Memberships @ $35.00 ea............................ ____________

[ ] Electrical Access $50.00................................................____________

..................................................................................TOTAL:__________

Put a checkmark next to Electrical Access if your are not sure if you
need it. We will contact you later to see if you do.