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 $ _____

Ticket holders must be at least 21 years of age

All Tickets are tax deductible to the extent allowed by law

Ticket Purchases will also be available online through the MDA Website