Print this form and return to:
CCHS
PO BOX 626
CARLISLE PA 17013
Please reserve _______ place(s) for the ______________________________________________________________________ trip
on the date of ____________________________________.
Name____________________________Address____________________________Phone________________E-mail if available__________________
*****
Payment Information
Check... Enclosed check for $____________________
_____for Member of CCHS
________non-member CCHS
Credit Card... _____ VISA _______Mastercard
3-digit number
Card #________________________________ on back of card______
Expiration Date____________
Signature______________________________________________
*****
Meal Information if applicable
I would like ___________ (number of meals) of the choice _______________________________________________________
(please list choice)
A copy of the official registration and financial information may be obtained from the Pennsylvania Department of State by calling toll-free within PA, 1-800-732-0999. Registration does not imply endorsement.