Please provide the following contact information:

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
Handicap
Team Players (please seperate by commas)

Select any of the following options that apply:

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Please reserve  spaces @ $50 per person

Hole Sponsor @ $100 per hole

Prize Donation of  for Golf Tournament  or   Awards Ceremony

Cash Donation of  for  Golf Tournament   Awards Ceremony

Choose the Method of Payment:

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Check enclosed

Check forthcoming

Please be advised:  This is not a secure server.  If you wish to use your credit card please call (859) 257-2820.

Charge  to my:  Visa  Mastercard              

Credit Card #   

Credit Card Expiration Date:  (mo/yr)

Cardholder's Name: