First Name: Last Name: Address: City:

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10th Annual Engineering Awards Banquet
Please fill out the following registration information for the 10th Annual Awards Banquet.
First Name:
Address:
City:
Phone Number:
Email:
Total Number of Tickets:
Last Name:
State:
Zip code:
Please provide the names of each person you are purchasing a ticket for below.
First Name
Last Name
Ticket cost: $25
___
A check is enclosed, made payable to the SIUE School of Engineering.
___
I wish to pay by credit card. (__American Express __Discover __MasterCard __Visa)
Card Number
Expiration Date
________________________________
________________________________
CSC Code (3 digit code on back of card)
Signature
To complete registration, if paying by credit card, please email this form to
[email protected] If paying by check print out form and mail form and
check to:
Theresa Wasylenko
SIUE School of Engineering
Campus Box 1804
Edwardsville, IL 62026 -1804
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