Please provide the following contact information (Bolded Fields Required):

First Name		Last Name
Title		Organization
Street Address
Address (cont.)
City		State/Province
Zip/Postal Code		Country
Home Phone		Work Phone
E-mail		FAX

Please provide the following ordering information complete with your Total:

Advanced Ticket Sales:

QTY	PRICE	DESCRIPTION
	$30	Adult(e)s
	$25	Students / Étudiants
	$25	Seniors / Âge D’Or
	$65	Family / Famille
		TOTAL

	BILLING
	Money Order or Cheque
	Sorry we cannot accept credit cards at this moment. We apologize for this inconvenience.

	Check here if same as above
	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Kapuskasing Economic Development Corporation
88 Riverside Drive
Kapuskasing , Ontario
P5N 1B3

TO FAX THIS FORM, SELECT THE PRINT OPTION UNDER THE FILE MENU
FAX TO 705-337-1741