Please fill out the following information in the form below.

Name ____________________________________________________________________________

Address __________________________________________________________________________

Email ____________________________________________________________________________

Telephone ________________________________________________________________________

I would like to attend the following: _________________________________________________________________________

__________________________________________________________________________________

Total Amount Enclosed _______________________________

Please make checks payable to Misty Kuceris and mail to:

Misty Kuceris; PO Box 1532; Springfield, VA 22151-0532

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