Name

Organization

Address

City, State, Zip

Daytime Phone Number

Fax

E-Mail Address of Contact (required)

Website
(patrons & sponsors only)

Payment option:

• If you are paying by check: Mail this completed form with your check to AFPNCOH, 703 South Main Street #211, Akron OH  44311.
• If you are paying by MasterCard or Visa: Print this form, write down your credit card information, and fax this completed form 330-315-0399.

Check

Charge my credit card:  __ Visa         __ Mastercard
       Will appear as “INFO LINE” on your statement

Number _____________________________ Exp _________

Signature ________________________Security Code_____

Ticket Order

Please reserve Patron Tickets @ $75 each for a total of $
     ($55 of each ticket is tax-deductible; patrons receive special recognition in the program and website)

Please reserve Friend Tickets @ $40 each for a total of $
     ($20 of each ticket is tax-deductible)

Please reserve Tables of 10 @ $450 each for a total of $
     ($250 of each table is tax-deductible; table sponsors receive special recognition in the program and website)

I am unable to attend, but I am sending my tax-deductible donation of
     $

Total Due:    
 

Those who will attend the luncheon
          (this will be used for nametags ... be sure to include yourself!)
 

First Name
(include special honorifics such as Dr. or Fr.)

Sample: Fr. Bob

Last Name
(include special special suffixes such as Jr. or Sr.)

Sample: Smith, Jr.