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2008 Iconology Workshop Registration Form
Name:_________________________________ Address:_______________________________ Phone #:_(____)_________________________ Cell Phone #:_(____)_____________________ Email:_________________________________ Fee: $350.00 includes all materials Payment method: VISA MC Expiry Date ____/______ Credit Card #:___________________________ Signature:______________________________ Date:__________________________________ Checks payable to: This Century Art Gallery Mail registration to: This Century Art Gallery-Williamsburg Visual Arts Center 219 North Boundary Street Williamsburg, Virginia 23187 ATTENTION: Lori Jakubow

2008 Iconology Workshop Registration Form

Name:_________________________________

Address:_______________________________

Phone #:_(____)_________________________

Cell Phone #:_(____)_____________________

Email:_________________________________

Fee: $350.00 includes all materials

Payment method:

VISA MC Expiry Date ____/______

Credit Card #:___________________________

Signature:______________________________

Date:__________________________________

Checks payable to:

This Century Art Gallery

Mail registration to:

This Century Art Gallery-Williamsburg Visual Arts Center
219 North Boundary Street Williamsburg, Virginia 23187
ATTENTION: Lori Jakubow