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Name : Private Bungalow $310
Address: Semi-Private Bungalow @$225/person
City, St Zip : Three Man Room @$175/person
Home Phone: Four Man Room@ $110/person
Work Phone: Total Amount:
(If you wish to choose
your roommate in a shared room, submit applications for each together.)
Make Checks Payable to
"FRIENDS OF CHOICES"
and mail to
|
FRIENDS OF CHOICES |
If you choose, you may fax this registration for credit card payment to: (310) 915-1973
Circle one: American Express Visa Mastercard
Total Amount to Charge (from above):
Card Number:
Expiration Date:
Name as it appears on card:
Credit Card billing Address:
Authorized Signature:
(Credit Card Transactions will be processed by Baytronics South, Los Angeles, CA.)