2010 Reach for a Cure Wine Tasting Thursday Night, April 22, 2010 AN EVENING SUPPORTING FRIEDREICH’S ATAXIA RESEARCH BROUGHT TO YOU BY THE MUSCULAR DYSTROPHY ASSOCIATION DONATED AUCTION ITEM AGREEMENT AUCTION ITEM: _______________________________________________________ ITEM DESCRIPTION: ___________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ITEM VALUE: $_____________________________ DONOR INFORMATION COMPANY NAME: _______________________________________________________ CONTACT NAME: _______________________________________________________ MAILING ADDRESS: ____________________________________________________ ______________________________________________________________________ EMAIL: _______________________________________________________________ PHONE: (_______) __________________________ PLEASE (pick one) ____ HAVE A COMMITTEE MEMBER PICK UP THE ITEM OR ___ SHIP TO MDA (ADDRESS BELOW) (All auction items must be received by MDA by Monday, March 26, 2010) COMMITTEE MEMBER SECURING ITEM: _________________________________________ TODAY’S DATE: __________________________________ PLEASE FAX THIS FORM TO MDA AT 770-850-0733 Or mail to: Muscular Dystrophy Association (MDA) Attn: Emily Clines 120 Interstate North Pkwy, Bldg. 4 #448 Atlanta, GA 30339 MDA Tax ID # 13-1665552 This form must be received by March 19, 2010 in order for the item to be listed in the event program.

Rev 09/24/09