Name(s): _______________________________________________________    

Tel.:    _______________________________________________________

Address: _______________________________________________________

         _______________________________________________________

         _______________________________________________________

Members: ______ x  $55  =   $ ________         Non–members: ______ x  $60   =   $________

Total: $ ________

Do you need a pick-up at Place Portobello?__________

Hold Harmless Clause:

I, the undersigned, hold the Zoological Society of Montreal harmless from responsibility to life, limb, or property resulting from any accident, regardless of whatever may be the cause, on the above advertised event.

Signature: ___________________________________

Date: ___________________________________