HTML Preview Institute Fundraiser page number 1.
Send this form to PARKLAND INSTITUTE
Edmonton Office: 1-12 Humanities Ctr, UofA, T6G 2E5
Phone: (780) 492-8558 Fax:(780) 492-8738
email: parkland@ualberta.ca website:www.parklandinstitute.ca
This is a fundraising event. Don’t forget your chequebook.
Parkland Institute
Gala Fundraiser Dinner Ticket Form
6 pm, February 17, 2016 U of A Faculty Club
Paid by:
Name
Address
City Prov. Postal Code
Phone(H) (W) Fax
Number of Tickets: _____ X $125 = $_____ # Tickets Donated Back: _____
Table size: 6, 8 or 10 seats. Table Name:____________________________________________
______Free seating (available for those who have not purchased in a group.)
Total: $______
Paid by: Cheque (payable to University of Alberta) ____
Visa ___ Master Card ____ # ___________________________ ___ /____ Expiry
__________________________________
Signature
Charitable tax receipts will be issued for portion of the ticket. Tickets donated back will be
receipted for $125 each. The charitable receipt will be sent to the person/organization that paid for
the tickets unless the following is checked and signed:
I have been paid for the ticket. Please send the charitable receipt to the ticket holder(s) below
as indicated.
Signed: ________________________________________________
Ticket For (If the same as above, fill in only the new information):
Name E-mail
Address
City Prov. Postal Code
Phone(H) (W) Fax
Vegetarian Meal ____ Send Charitable Receipt: ____
Other dietary requirement_______________________________________________________________
Attach additional names and contact information if required.
RSVP by February 12 for dietary needs