Please return this form by mail to:
IC Annual Forum
1263 E. London-Groveport Road, Lockbourne, OH 43137

Last Name (Print) _______________________________First Name_______________________________

Street Address ____________________________________________________

City ______________________________ State __________ Zip ________

Home Phone __________________________________________________

Email Address ______________________________________ (to confirm registration, which will include a map and list of local hotels)

Names of those attending____________________________________________________________________

Price $25 for 1 or $40 for a couple. I have enclosed my check or money order in the amount of $ __________, payable to: IC OHIO
Number of people in my group _________
(Please keep a copy of this form for your records)