Registration Form

2021 NULIAQ ART WORKSHOP

    Vladimir Zhikharsev, Instructor

PASSENGER NAME(S): __________________________________________________________________________________________________

EMAIL:  ________________________________________________________    CELL/TEXT:___________________________________________

CITY & STATE FROM WHICH YOU ARE ARRIVING:_________________________________________________________________________

DO YOU HAVE ANY SPECIAL DIETARY REQUIREMENTS OR LIMITATIONS?  If so, please note below or on reverse side. _____

DEPOSIT ($1,000 per person) ENCLOSED  $______________________       CHECK NUMBER: _________________

Please make check payable to:     Phyllis Tate 

and MAIL WITH THIS FORM to:     P.O. Box 71027

                                                       Fairbanks, AK 99707

EVIDENCE OF COVID-19 VACCINATION(S) FOR ALL PASSENGERS IS ENCLOSED. ________________________________________                                                                                                                                                     Signature of Applicant(s)

Don't hesitate to contact us if you have questions!!

     Vladimir  (907) 699-5588                                         Phyllis   (907) 699-1025                                       Murray    (907) 699-8283