JLF BANQUET 2017 TICKET REQUEST FORM

I would like the following number of tickets for the Jack London Birthday Banquet to be held on January 14, 2017

[ ] Member(s) & guests @ $60 [ ] Non-Member(s) @ $80 [ ] High School Student(s) @ $35

Name(s) of Individuals attending:

______________________________________________________|____________________________________________________

First Name Last Name | First Name Last Name

______________________________________________________|____________________________________________________

Seating will be assigned on first come first served basis. People listed above will be seated together. $2.00 Service Card will be added to any card used.

[ ] Check enclosed Charge to: [ ] Visa [ ] MasterCard [ ] American Express

Card Number_______________________________Exp Date ____/_____CVS_________

 Signature________________________________________Phone Number _______________________

E-mail____________________________________________ Zip Code _______________-