EFTA02698539.pdf

HAITI Cagy/ilea ein/ C6api/05 A Gala For Haitian Relief Benefiting J/P Haitian Relief Organization, Artists for Peace and Justice, Happy Hearts Fund The Agora Pavilion at the Cannes International Film Festival Friday, May 18, 2012 - 9:30PM - TICKET/TABLE REGISTRATION FORM - Name (as it should appear on any printed materials) Company No listing please El Address City State/Country Zip/Postal Code Tel Fax Email I/We wish to reserve $100,000 MARDI GRAS - TABLE FOR 12 • 5 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh • Premiere placement in the room l/We wish to reserve $75,000 BAND MASKE - TABLE FOR 10 • 2 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh l/We wish to reserve $50,000 BAND A PIED - TABLE FOR 10 All table purchases will receive acknowledgement in the program as a category respective supporter. For inclusion in the program, tables must be purchased by May 8, 2012. l/We wish to reserve $7,500 BAND MASKE TICKET l/We wish to reserve $5,000 BAND A PIED TICKET I/We cannot attend, but would like to make a contribution in the amount of $ Please bill my: AmEx El Visa El MasterCard D Diners Club in the amount of US$ Credit Card Number Exp: Security Code: Signature If Corporate Card, Name of Company Bank Transfer: I am transferring funds in the amount of US$ to C. National Bank ABA # Sr credit to J/P Haitian Relief Organization -Account Checks. made payable to J/P HRO. m ailed to 6022 Wilshire 81vd, Suite 203, Los Angeles, CA 90036. For further inlormation, please call the RSVP Information lineal or email All tkkets are non-refundable. For U.S. residents. $350.00 of each ticket is a non-tax-deductible charge for food, beverage, an entertainment. Payments in excess of $350.00 per person and contributions in return for which no goods or services were received are tax deductible as a charitable contribution.Check. made payable to J/P HRO. J/P HRO Tax ID 27-17032371. Donations will be processed by J/P HRO and benefit all three organizations. Given limited ticket availability for this event, this form is intended only for the person to whom it was addressed and is non transferable. NI) HAITIAN RELIEF ARTISTS 14111) ORGANIZATION `MACE JUSTICE • Neckt-MC 443) Cwt FESTIVAL OE CANNES GIORGIO ARNIAM WAfrati Please fax this form to r email regardless of payment method EFTA_R1_02059149 EFTA02698539