Print out this form and return with payment to Athens County Democratic Party, P.O. Box 191, Athens, Ohio.

Reservations and payment must be received by October 10th 2008.  Reservations are on a first come first serve basis

so make your reservations early as this dinner may sell out. 

 

 

 

ATHENS COUNTY DEMOCRATIC PARTY
REPLY INFORMATION
Contact: Debbie Clary 740-331-4893 or dlclary@gmail.com
Information for each paying Guest
NAME: ________________________________________________________________________
ADDRESS: _____________________________________________________________________
CITY, STATE, ZIP______________________________________________________________
PHONE: ______________________________________________________________________
E-MAIL:_______________________________________________________________________
OCCUPATION: ________________________________________________________________
EMPLOYER: __________________________________________________________________
[If self-employed state Business Name]
Method of Payment: __ CHECK ___MASTER CARD or VISA
_____ I would like to contribute $50 each for a College Democrat Student Ticket (Add to Payment)
AMOUNT: _____________ Individual tickets are $50 each\$500 (Sponsor Table of 8). If you have more
than 2 individual tickets please provide the above information for each person. You may copy this form
or provide the information on another sheet of paper.
(over)
VEGETARIAN MEAL
________________________________________
Page 2
CREDIT CARD PAYMENT INFORMATION
CARD NO._______________________________________________________
NAME ON CARD: _______________________________________________
BILLING ADDRESS: _____________________________________________
EXPIRATION DATE: _________________
3 DIGIT CODE (FROM BACK OF CARD) __________
MAKE CHECKS PAYABLE TO: ACDP, P.O.BOX. 191, ATHENS, OH, 45701

Paid for by ACDP, Susan Gwinn, Chair