9/11 SHS Memorial 6^th Annual Patriot Award Dinner

(www.shs911memorial.org)

9/11 SHS Memorial 6^th Annual Patriot Award Dinner

Tuesday, July 1, 2008 - 7:00pm - Woodbury Country Club

Please Respond By June 18^th - Cost Per Person: $100.00

        I will attend

    Number of guests - check enclosed $

        Cannot attend; donation enclosed $

Please make checks payable to: SHS 9/11 Memorial Fund.  Please mail all forms and checks to: SHS 9/11 Memorial Fund, P.O. Box 2425, Seaford, NY 11783

Please PRINT or type clearly

 Name:

 Address:

 City: State: Zip Code:

 Phone Number: () 

 Email Address:

 Please list names of guests and seating preference in space below

Please make checks payable to: SHS 9/11 Memorial Fund.  Please mail form and check(s) to:  

SHS 9/11 Memorial Fund, P.O. Box 2425, Seaford, NY 11783

For credit card payment, fill in the additional information below then print, sign and Mail to above address:

           Please select payment type:    AMEX     MasterCard    Visa     Check 

 Card Number: (15 digits for AMEX - 16 digits for all other cards)

 Exp. Date:            Security Code:

(security code is three digits on the back of your card after your account number OR four digits on front of card for AMEX above last four digits of your account number)

 Name on Card:

Signature ________________________________________________________________ 

 TOTAL PAID = $   Thank You.