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Registration Deadline is April 30th.

If you purchase more than one ticket, someone will contact you to obtain the names of your guests.

Questions? Contact us.

REGISTRATION FORM
	Platinum Sponsor ($5,000) : 2 Tables of eight, one for your company, one to donate to charity, 1 year web site advertising contract, logo projected on screen, verbal recognition at event.
	Gold Sponsor ($2,500): 2 Tables of eight, one for your company, one to donate to charity, 6 month web site advertising contract, logo projected on screen.
	Silver Sponsor ($1,000): 2 Tables of eight, one for your company, one to donate to charity, logo projected on screen.
	Table(s) of 8, $320 each.
	Individual, $40 per person. How many seats would you like?
	We are unable to attend, but would like to make a contribution. Amount you wish to donate?

GRAND TOTAL
	Grand Total:

YOUR INFORMATION
Name:	*
Company Name:	*
Address:	*
City:	*
ST:	*
Zip:	*
Phone:	*
Email:	*
	* - required field
Please list the names of those with whom you would like to be seated:

PAYMENT OPTIONS
Please to pay on-line. You will be directed to our secure partner site, Paypal, to pay by check or credit card. If you would prefer not to take advantage of our on-line payment option, please to submit your information via email and mail your payment to: Make a Difference Michiana, Inc. P. O. Box 4073 South Bend, IN 46634 Phone: (574)232-3660 ext. 214

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The Make a Difference Michiana logo is a service mark of Make a Difference Michiana, Inc. All rights reserved. © 2008 MAKE A DIFFERENCE MICHIANA. All Rights Reserved. Disclaimer