Name(s): ___________________________________    

Tel.:    ___________________________________

Address: ___________________________________

         ___________________________________

         ___________________________________

Number of persons:         Members ______ x  $50    Enclosed $ ________

Non–members ______ x  $55     Enclosed $________

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: ___________________________________