Official Dinner & Show Coupon
This is a
Black tie
event
or
Classic
Costume
Page 2
CRYSTAL REEL AWARDS
Payment options:
Check _______
Credit Card (circle one) VISA MASTERCARD
Card # _______________________________________________
Exp. Date ___________________ Security code _____________
Name on card _________________________________________
Signature _____________________________________________
Office only
Received on ____________
Total Amount ____________
Approved ______________
Entered by ____________________
Please Print
Name: ___________________________________________
Address: _________________________________________
City ________________________ St _____ Zip _________
Phone _____________________ Work ________________
Email ___________________________________________
Dinner Choice:
Sirloin Steak___________
Chicken Marsala ________
Grouper _________
Vegetarian upon request
EARLY BIRD SPECIAL
Tickets purchased before August 15th $60.00
Tickets purchased after 8/16 until 9/19 $75.00
Final Date of purchase is Sept 19, 2007
PURCHASE EARLY AND SAVE
Send to: Dale Johnson
392 Lakeview Terrace
Palm Harbor, FL 34683
or include with entry
Print Form
