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