Please
Print and return this registration form via mail or fax to:
United
Mitochondrial Disease Foundation
Attention:
Ashley DiLorenzo
7725 Wentworth
Drive, Duluth, GA
30097
770-622-5493
phone/fax
e-mail: ashleydilorenzo@yahoo.com
________________________________________
Name
________________________________________
Company
________________________________________
Address
________________________________________
City
State
Zip
________________________________________
Phone
________________________________________
Email Address
Players:
(all skill levels welcome)
Name
Handicap
__________________________
_______
__________________________
_______
__________________________
_______
__________________________
_______
Select
Sponsorship Level(s):
o
Platinum Sponsor
$10,000
o
Gold Sponsor
$5,000
o
Silver Sponsor
$2,500
o
Bronze Sponsor
$1,000
o
Golf Foursome
$700
o
Individual Golfer
$195
each
o
Goody Bag Sponsor
$3,000
o
Dinner Sponsor
$2,000
o
Driving Range Sponsor
$1,000
o
Beverage Sponsor
$750
o
Hole Sponsor
$250
o
I am unable to attend, but would like to make a donation to
UMDF $
___________
Method
of Payment:
Total
amount due:
$________________________
o
Check Enclosed (Payable to: United
Mitochondrial Disease Foundation)
o
MasterCard
o
Visa o AMEX
Credit Card
Number _____________________________ Expiration ____
/____
Cardholder’s
Name ______________________________
Point
of contact for camera-ready artwork:
Name:
_____________________________
Phone:
_____________________________
Email:
_____________________________
UMDF Tax
ID: 25-1767180
