Gala VI Sponsorships

Count me in! I want to participate as a Sponsor for Gala VI, June 20-22, 2008. The evening will support the purchase of a Multi-detector CT Scanner for The James D.Conzemius Heart Center at Flagler Hospital.

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Sponsor Information

I would like my name or company name to appear for recognition purposes as follows:

Name:*

Business Organization:

Address:*

City:*

State:*

Zip Code:*

Telephone:*

Email:

For recognition purposes, list this sponsorship as:

Sponsorships

Two-Night Packages

Diamond Sponsor $20,000

Gold Plus $12,500

Silver Plus $7,000

Ruby Plus $2,000

One-Night Packages

Platinum Sponsor $15,000

Gold Sponsor $10,000

Silver Sponsor $5,000

Ruby Sponsor $1,500

In addition to my sponsorship, I would like to purchase:

Number of Gala Tickets, each $250

Number of Drawing-By-Chance Ticket(s) $100

Sorry, a full sponsorship is not an option for me this year, though I would like to support The Heart Center with a gift in the amount of

$ is included.

Payment Method

Please invoice me.

Secure Credit Card Payment

Cardholder Name:*

Credit Card Type:*

Card Number:*

Expiration Date:*