Please complete this form
clearly and print. One person per form.
First name:
M.I: Last name:
Address:
Apt:
City:
State:
9-digit Zip Code:
Email:
VP#:
FAX:
Please pick only one of 8 "dot" selections.
Registration only Free
Registration and brunch
at Marriott Hotel (Sunday morning) $20.00
*
Sunday brunch at Marriott Hotel, u pay the Marriott clerk
before enter the private room for Class 0f '65
Please
return this registration form and make a personal check,
cashier’s check or money order, payable to ‘Class of 65’,
Attn: Tom Garro, ???????????????????, Connecticut
09999-9999. No Personal check accepted
after September 1, 2010.
Click the "BACK" button to return the
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