Souvenir Journal Contract

Name/Company Name  _______________________________________________

Address: ___________________________________________________________

Phone:  _______________  Email Address:  _______________________________

I want to sponsor for

• Inside front cover  ____________
• Inside back cover ____________
• Back cover  _________________

Inside Pages

• Full page ______________

• Half page ______________

[ ] Please check if you want to attend the Forum of which you network with other business professionals.

Please note that this serves as a contract with your signature affixed.
To use VISA or Master Card or Amex for Deposit, and Balance, please fill out below:

Visa:  ______________________________  Good Thru:  _____________________
Master Card:  ________________________  Good Thru:  _____________________
Amex:  _____________________________  Good Thru:  _____________________

Name on card [please print] _____________________________________________

Signature:  _______________________________  4-digit card ID#:  _____________

SPECIAL MESSAGE INSTRUCTION:
____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Thank you for your kind participation.  Your support is most appreciated.

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            Sponsor’s Signature                                                             Date