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Dizzy's 'Degustation' Dinner               Booking Form

18th December 2008 at 7pm.
GIL LANGLEY ROOM BRADMAN STAND - ADELAIDE OVAL


Your First Name
Your Last Name
Email Address
Address
Suburb
Postcode
State
Phone
Credit card details
Credit Card Type
Credit Card Number
Credit Card Expiry /

I am permitted to use the above credit card and
I am over 18 years of age

I would like to book for:

place(s) at $250 each.