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Presented by: National Certified Insurance, Inc. Wednesday, April 22, 2015 ~ 11:30 a.m. - 1:00 p.m. DoubleTree Hotel ~ 3100 Camino Del Rio Court
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Company Name: _________________________________________
Phone #: _____________________
Contact Name: __________________________________________
E-mail: _____________________
Address: _______________________________________________
Zip: __________
_____ # of Individual lunches x $50 =
$ ________
_____ Table for 8 Sponsorship x $500 =
$ ________
_____ Table for 10 Sponsorship x $600 =
$ ________
TOTAL:
$ ________
Raffle Prize Sponsor: Donation of : Value:
___________________________________ $ __________________
VISA/Master Card/AMEX: Card #: _______________________________________ Exp: ____/____ CVN: ______ (3 digit code on back of card)
BARC Mission Statement To build a stronger community by helping people with Intellectual and Developmental Disabilities achieve individual goals for a better life.