TICKET REQUEST FORM

    LAST NAME                                                     FIRST NAME                                   

________________________________________________________________________

    PHONE #                                                            EMAIL ADDRESS

STREET ADDRESS/P.O. BOX                                 CITY              STATE           ZIP

NUMBER OF TICKETS   ________        @ $20/ea JLF members  = Total   $_________

NUMBER OF TICKETS   ________         @ $25/ea nonmembers  = Total   $ _________

Mail check to :  Jack London Foundation

                                    P.O. Box 337

                                    Glen Ellen, CA +5442-0337

Or E-mail completed from to: jlondon@vom.com

If you wish to use a credit card (Visa, Master Card or American Express) there will be a $5.00 service charge.

Name on Card: ___________________________________________________________

Number ______________________________________ Exp. Date ________/_________