VALENTINE'S GALA 2014 TICKET PURCHASE

PURCHASER INFORMATION

Company Name (optional):
First Name *required:
Last Name *required:
Email *required:
Address *required:
City *required:
Province/Territory
Postal Code *required:
Daytime or Cell Phone Number *required:

TICKETS

Number of tables
x $5000.00
Name you would like the table to be under *required:
Mailing Address (if different from billing):

PAYMENT

Card Type (Required):
Cardholder Name *required:
Please ensure this exactly matches the name on the card.
Card Number *required:
Card Expiry Date *required:

For purchasing less than a table please contact Mary Cousineau at 780.497.3261 or mary.cousineau@delcongroup.com