Name

Organization

Address

City, State, Zip

Daytime Phone Number

E-Mail Address (required)

Sponsor Level:

Hometown Sponsor: $1,000 ($920 tax deductible)
Vanguard Sponsor: $500 ($420 tax deductible)
Display Sponsor: $250 ($190 tax deductible)

Total amount you will pay:

$

Payment option:

Check

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

Number _____________________________ Exp _________

Signature ________________________Security Code_____

• 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.