Oregon Cycling Conference email Registration Form

Name __________________________________________ 

Address ________________________________________ 

City ___________________ State ____ Zip _________ 

Phone number _____________ email ________________ 

Ticket information :
number at total
Conference only _____ ($30ea) _______
Conference and OBRA Banquet _____ ($45ea) _______
OBRA Banquet only _____ ($25ea) _______

Total ________

Please make check out to: Cycling Conference and Banquet 
Mail to: Cycling Conference, c/o Jerry Powell, 
         1926 SW Madison Street
         Portland OR, 97205

Be sure to mail by January 12, 2003, the deadline for 
guaranteeing a seat is Thursday, January 15th so I have 
to have your check by then.