SAC 2004 EXTRA BANQUET TICKETS FORM

Surname: _________________________  Given Name: _______________________

e-mail: _____________________________________


Extra banquet Tickets @ $50 each:                  ( )x$50....$________


Method of Payment:[ ]Credit Card   [ ]Cheque in Canadian funds
                  (payable to "University of Waterloo")
                                                                   
Payment by Credit card (select one):    [ ]Visa     [ ]Mastercard

Name on Card: __________________________________________

Card Number:  ___________________________ Expiry Date: _____/_____(mo/yr)

Cardholder's signature: ________________________________

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Is a vegetarian meal required for the banquet?   YES ___    NO ___ 

Please indicate any other special dietary requirements:

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Mail or FAX this form to:	Attn: Janet Bullock, SAC 2004
                                Dept of Elect & Comp Eng
                                University of Waterloo, Waterloo, ON
                                Canada N2L 3G1
                                Fax:   +1 519 746 3077
                                Phone: +1 519 888 4567 Ext. 5771