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Electra Business Awards 2011 Function Registration - Friday 4 November

Earlybird ticket price:     $99.00
Late ticket price (purchased after 20 September):   $115.00
Table of 10   $950.00

Please fill in the form below to register for tickets.

Contact Person

First Name *  
Last Name *  
Business Name *  
Phone Number (must include area code) *  
Email Address *  
Address *  
Suburb 
City *  
Post Code 
Number of tickets you're purchasing *  
I/we would like to sit with Kapiti Chamber of Commerce guests: 
Any special dietary requirements: 

Payment

Total amount due
(Based on the ticket prices shown below) 

There are three ways that you can pay for your tickets
Please indicate which form of payment you will be using:

Earlybird ticket price = $99.00 inc GST
Late ticket price (purchased after 20 September) = $115.00 inc GST
Table of 10 = $950.00 inc GST
 Cheque
Credit Card
Online Payment

   * Required Data

If you are paying by credit card, please click here to download the Credit Card Payment form.

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