KEY-ACTION NETWORK

Presents
ANNUAL BENEFIT DINNERAND DANCE
Friday October 17, 2014 6: 00 pm to 1: 00 am
Ticket Order Form

Tickets:
_____ tickets at $50 each=$______________
Full Reserved Table of 10- $450
General Donation of $100 or $_________________
Please invoice me. (Business Orders Only)
Payment by MasterCard, Visa or American Express. (Please Circle)

If purchasing a full table, your company name will be on the card reserving your
table.
Your Contact information:
Business Full
Name:___________________________________________________________________________________________
__________________

Contact Person: _______________________________________________________

Email: _____________________________________________________________
Address: ____________________________________________________________
City: ______________________________ Prov: _________ Postal Code: _________
Home Phone: _____________________________
Business Phone: ______________________Business Fax: ___________________
Credit Card Number: ________________________________________________
Expiry Date: _____________/_________ CVC Number on back: ____________________

Tax receipts will be issued within 90 days of the event as the amount will depend on Revenue Canada
allowance. Receipt will be sent to the address above.
Please return form to: Key Action Network Benefit Dinner
U4-444 Stone Church Road West
Hamilton ON L9B 1R1
Fax: (905)390-3582
Ticket Numbers Sold:
Ticket Representative that sold tickets: (print name)
________________________

___________________________________________

UNITED IN LOVE, COMPASSION AND CARE FOR ONE ANOTHER