Old Dominion Chapter, NRHS

2009 James River Rambler Order Form

Name:  _________________________________________________________________________________

Address:  _______________________________________________________________________________

Address 2:  ___________________________________  Email:  ___________________________________

City:  _________________________________ State: _____  Zip:  ________________________

Home phone:      __________________________Work phone:  ____________________________

Dillwyn to Johnson 1.5 Hour Trips

Please indicate next to acceptable times “1” for first choice, “2” for second choice, etc.  We will fill the order based on this information, going in order of preference.  If we are unable to fill your order following your order of preference, your order and payment will be returned to you.

_____May 9th, departing at 9:30 am, returning at 11:00 am

_____May 9th, departing at 11:30 am, returning at 1:00 pm

Number of Johnson adult tickets: ______     Number of Johnson child (age 2 through 12) tickets:  ______

Cost of adult tickets $12.00:                    Cost of child tickets $6.00:                    Total:

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Dillwyn to New Canton 3.5 Hour Trips

Please indicate next to acceptable times “1” for first choice, “2” for second choice, etc.  We will fill the order based on this information, going in order of preference.  If we are unable to fill your order following your order of preference, your order and payment will be returned to you.

_____May 9th at 1:30 pm

_____May 16th at 9:30 am             _____May 30th at 9:30 are

_____May 16th at 1:30 pm             _____May 30th at 1:30 pm

Number of New Canton adult tickets: ______     Number of New Canton child (age 2 through 12) tickets:  ______

Cost of adult tickets $22.00:                    Cost of child tickets $ 11.00:                    Total:

Check Number (if applicable): __________

Credit card number: ____________________________________Card Exp Date (mm/yyyy):_____________

Cardholder name if different: _______________________________________________________________

Cardholder signature:   __________________________________________________________

Please print this form and send to:  Old Dominion Chapter, NRHS, Attn:  Excursion Ticket Sales, P O Box 1323, Colonial Heights, VA  23834-3046.