Number of tickets requested:

Please provide the address you would like your tickets mailed to:

Name:

Address:

Address (contin.):

City:

State:

Zip Code:

E-mail address:

Home phone:

Work phone:

Credit Card Authorization

I authorize a charge against my credit card for 5 or less tickets at $29.00 per ticket

I authorize a charge against my credit card for 6 or more tickets at $24.00 per ticket

Total amount to be charged:

Credit Card (choose one):

Master Card

Visa

Name (as it appears on card):

Card Number

Expiration Date:

Mailing address:

Mailing address (contin.):

City:

State:

Zip Code:

How did you hear about this event? (choose all that apply)

From a council member

Saw a poster hanging in your place of employment

Saw it on our website

Read about it in the MRN newsletter

Read about it in another publication

Heard about it from a friend/colleague