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First Annual Golf Outing PRESENTED BY PARK & SIXTH COMFORT FOOD Monday, May 17, 2010

WHITE BEECHES GOLF & COUNTRY CLUB HAWORTH, NEW JERSEY

GOLFER REGISTRATION FORM

I/WE WOULD BE HONORED TO SUPPORT YOUR EFFORTS IN THE FOLLOWING WAYS Attending the golf tournament on Monday, May 17, 2010 as:

Individual Golfer (including all of day’s events)

$250

Foursome (including all of day’s events)

$1,000

Name of individual golfer:

1. ______________________________________________________________________________________________

Names of foursome players:

1. ________________________________________________ 2. __________________________________________________

3. _______________________________________________ 4. __________________________________________________

Please provide the following information: Name:________________________________________________________________________________________ Address:_____________________________________________________________________________________ City: ___________________________________________________ State: ___________________ Zip: ____________ Phone: _______________________________________Email Address: _____________________________________

Payment Enclosed is a check made payable to: Konabona, llc. or please charge:

AMEX

MC

VISA

DISC

_____________________________________________________________________________________________________________ SIGNATURE

NAME AS IT APPEARS ON CARD

______________________________________________________________________________________________________________ CREDIT CARD NUMBER

EXPIRATION DATE

Please complete this form and return to Josie Di Chiara Di Chiara Marketing Group 537 Park Avenue Hoboken, New Jersey 07030 or via fax to: 201-710-5021 If you have questions, call Josie directly at 201-208-4540


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