District 70 Changeover Dinner

Please complete this form in order to register one or more people to attend the District Changeover Dinner,
charging the cost to a credit card. Note that this is not an e-commerce action.

When you submit the form, you will be shown a page confirming your data entry.
This data is not stored on our web server or any other computer. Rather it is sent as a text
email message to District 70, where it is printed and processed along with registrations
received by post. If you wish, you can avoid having your full credit card number appear in the email
message sent to us from the form by following the procedure explained at the bottom of this form.

Should you need to correct any details or if you have any special dietary or other requests
please send a follow up email to the Changeover Dinner Chairman.

Please provide the following details:

(Use the TAB key or your mouse to move through the form.)

First Name
Last Name
Phone Home Work Mobile (select one)
Email
Club (one only)

Number attending

  

Payment details

Credit Card
Cardholder Name
Card Number
    
Please leave spaces between each group of 4 numbers.
Expiration Date
Amount to be charged (Number of people x $39 per person)

Note: If you are concerned about your credit card number appearing in an email message, then include only the first 8 digits in the box above. After submitting
this form, follow it up by sending an email to the Changeover Dinner Chairman.
giving your name and the remaining digits on your credit card.

                                                                         

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Toastmasters International District 70
Revised: 28 April, 2008