Ticket Form

2010 Reach for a Cure Wine Tasting

an evening supporting Friedreich’s Ataxia research

Brought to you by the Muscular Dystrophy Association

The Westin Atlanta Perimeter North

April 22, 2010

http://www.ReachforaCureFA.org

Name: _____________________________________________________

Address: ___________________________________________________

City, State, Zip: _________________________________________

Email: _____________________________________________

Phone: _________________________________
Fax: ___________________________________  

_____          Please register me for this event. 

_____ My check (made payable to MDA – Reach for a Cure) will follow via mail   OR

_____ I will call the MDA office to pay by credit card (Visa, MasterCard, Discover, and American Express)

_____          I won’t be able to attend, but please accept my donation of  $_____________ to follow via mail.

 I desire to purchase _______ Individual Tickets @ $65 each

Total Purchase $ _____

All tickets must be purchased before the day of the event -- Tickets will not be sold at the door

Ticket holders must be at least 21 years of age

All Tickets are tax deductible to the extent allowed by law