EmailMe Form - TWENTY TWELVE D'MAYAN EMPIRE

TWENTY TWELVE D' MAYAN EMPIRE-OverseasRegistration
Please review all information thoroughly before submission of form

Name *

Address *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Phone *

###

####

Alternate Phone Number

###

####

Email *

Birthday *

YYYY

Identification Type (Passport, Drivers License, Etc.)

This will be used for costume collection purposes

Identification Number

This will be used for costume collection purposes

Costume Information and Sizing

Male/Female *

Section Desired *

Headpiece Style *

Top Size *

Bra Size

Bottom Size *

Belt Size in Inches (Measurement of where you want the belt to fall on the waist.)

Additional Information

Payment Infomation

All overseas orders are to be paid by Western Union ONLY. All orders are to be paid in full by February 15th, 2012. There will be absolutely no refunds

Payment Confirmation Number *

Payment Amount