Registration

An Evening with Henry Winkler - Individual Ticket Purchase
Date	8/12/2010
Time	6:00pm VIP Cocktail and Light Supper Reception 7:30pm General Admission
Location	The Cleveland Play House 8500 Euclid Avenue
Individual Ticket Prices	VIP Ticket ($150 tax deductible) - $225 VIP Ticket (Under 40 years old) ($50 tax deductible) - $125 General Admission ($75 tax deductible) - $100

Registration Information
First name
Last name
Company Name
Street address
City
State
Zip
Daytime phone with area code
Evening phone with area code
Fax with area code
Email address

Payment Information
Number of Tickets You Wish To Purchase	VIP Ticket ($150 tax deductible) at $225 each VIP Ticket (Under 40 years old) ($50 tax deductible) at $125 each General Admission ($75 tax deductible) at $100 each
Total Amount
Type of credit card
Name as it appears on the card
Credit card number
Expiration date

If you prefer to pay by check:

Please make it payable to:
Jewish Family Service Association of Cleveland

Print this form and mail with check to:
Jewish Family Service Association of Cleveland
3659 South Green Road, Suite 322
Beachwood, Ohio 44122

Please send me news and information about JFSA

(Once pressed, please wait for processing)