2012 Foundation Ball Registration

Reservations

Includes dinner, beverages, entertainment, and listing in program

* Payments in excess of $50 per person is tax deductible

Grand Patron:

$150/person

Grand Patrons

Grand Patron Guest 1: *

Grand Patron Meal 1: *

Grand Patron Guest 2: *

Grand Patron Meal 2: *

Grand Patron Guest 3: *

Grand Patron Meal 3: *

Grand Patron Guest 4: *

Grand Patron Meal 4: *

Patron:

$125/person

Patrons

Patron Guest 1: *

Patron Meal 1: *

Patron Guest 2: *

Patron Meal 2: *

Patron Guest 3: *

Patron Meal 3: *

Patron Guest 4: *

Patron Meal 4: *

Please seat us with the following guests

Company or individual name as it should appear in the program.

Company Or Individual Name: *

Billing Address: *

City: *

State: *

Zip Code: *

Fax:

Email: *

* IRS regulations stipulate that registration fees are not tax deductible if there is the opportunity for you to win a prize that is worth more than the cost of the registration fee. Check with your tax advisor if you have any questions. Make checks payable to: The Wilson Memorial Hospital Foundation. Mail to Wilson Memorial Hospital, c/o Cashiers, 915 W Michigan St., Sidney OH 45365. Thank you.

Total: $