TICKET ORDER FORM
Please fill out and return the following information to:
JDRF
Metro Detroit & S.E. MI Chapter
24359 Northwestern Hwy., Suite 125
Southfield, MI 48075
Phone: (248) 936-1290
Fax: (248) 355-1188
Email: [email protected]
Name_____________________________________________________________________________________________________
Company__________________________________________________________Title____________________________________
Address___________________________________________________________________________________________________
City________________________________________________State______________Zip Code____________________________
Phone____________________________________________Email____________________________________________________
(Please write quantity in box)
Mail in ticket deadline April 21, 2017
Benefactor Ticket -- $400 each
Includes cocktails, dinner, entertainment, and name
listed as Research Benefactor on signage at event.
_________________________________________________
Name as you would like it to appear on event signage
Benefactor Table of 10 Guests -- $3,900
Includes cocktails, dinner, entertainment, and name listed
as Research Benefactor on signage at event.
_________________________________________________
Enclosed is my check in the amount of
$__________________________________________
Make payable to: JDRF
Please charge my (check one)
Visa
American Express
MasterCard
Discover
Card Number
Name as you would like it to appear on event signage
Exp. Date _______/_______/_______ CVC_______
Patron Ticket -- $300 each
Includes cocktails, dinner and entertainment.
Patron Table of 10 Guests -- $2,900
Includes cocktails, dinner and entertainment.
Fair market value of one ticket is $100. Balance is tax deductible.
________________________________________
Card Holder Name
________________________________________
Authorization Signature
Thank you for your support of the
2017 Promise Ball!
Please provide your guest names on page 2 by April 21.
G U E S T I N F O R M AT I O N
Please provide list of names and addresses of guest no later than April 21, 2017.
Please note any dietary restrictions a guest may have next to their name.
1. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
2. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
3. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
4. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
5. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
6. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
7. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
8. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
9. Name ________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________
10. Name _______________________________________________________________________________________________________________
Address______________________________________________________________________________________________________________
Thank you for your support of the
2017 Promise Ball!
Please return to Jessica Bazner at [email protected]
or by fax at (248) 355-1188 by April 21.