Jack London Foundation BANQUET TICKET REQUEST FORM
I would like the following number of tickets for the Jack London Birthday Banquet to be held on January 14, 2012
[ ] Member(s) and guests @ $60 [ ] Non-Member(s) @ $80 [ ] High School Student(s) @ $35

Name(s) of Individuals attending:
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First Name Last Name | First Name Last Name
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Seating will be assigned on first come first served basis. People listed above will be seated together.
[ ] Check enclosed Charge to: [ ] Visa [ ] MasterCard [ ] American Express

Card Number_______________________________Exp Date ____/_____

Signature________________________________________


Mail To:                Jack London Foundation, P.O. Box 337, Glen Ellen, CA 95442