Big Apple Circus Ticket Reservation Form (please type answers, print, and mail or fax this form) Name: Address: City: State: Zip: Day Telephone Number: Evening Telephone Number:() () E-mail: Ticket Information adult tickets @ $35 per ticket $ senior tickets @ $25 per ticket $ child tickets @ $25 per ticket $ TOTAL # TICKETS $ TOTAL DUE Tax-deductible information: $ 20 per adult ticket $ 10 per senior / child ticket Tickets to be picked up at: Chapter office (September 10 - 21, Mon - Fri, 9 am - 5 pm) Will Call (day of event) Enclosed is my/our check for: $ (please make check payable to the Alzheimer's Association, NCA) or Credit Card Information: Visa Mastercard American Express Account Number: Expiration Date: Name on card: Signature: (please do not type; print and then sign in pen ink) Date: Please send completed form, along with payment, to: Alzheimer's Association, National Capital Area 11240 Waples Mill Road, Suite 402 Fairfax, VA 22030 (FAX) 703/359-4441 Phone: toll-free (866) 259-0042 © 1997 - 2001 Alzheimer's Association, National Capital Area. All rights reserved.
(please type answers, print, and mail or fax this form)
Name:
Address:
City:
State: Zip:
Day Telephone Number: Evening Telephone Number:() ()
E-mail:
adult tickets @ $35 per ticket $ senior tickets @ $25 per ticket $ child tickets @ $25 per ticket $ TOTAL # TICKETS $ TOTAL DUE
Tax-deductible information:
$ 20 per adult ticket $ 10 per senior / child ticket
Tickets to be picked up at:
Chapter office (September 10 - 21, Mon - Fri, 9 am - 5 pm) Will Call (day of event)
Enclosed is my/our check for: $ (please make check payable to the Alzheimer's Association, NCA)
or
Credit Card Information: Visa Mastercard American Express
Account Number: Expiration Date:
Name on card:
Signature: (please do not type; print and then sign in pen ink)
Date:
Please send completed form, along with payment, to:
Alzheimer's Association, National Capital Area 11240 Waples Mill Road, Suite 402 Fairfax, VA 22030 (FAX) 703/359-4441 Phone: toll-free (866) 259-0042
© 1997 - 2001 Alzheimer's Association, National Capital Area. All rights reserved.