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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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