Registration Form |
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| Name __________________________________________________ | ||
| Address ________________________________________________ | ||
| City ________________________ | State ________ | ZIP __________ |
| Home Phone ____________________ | Work Phone ________________ | |
| Number of Guests ________ ($50.00 by 1/18/08, $60.00 after) | ||
| In addition to myself, I am paying for: | ||
| __________________________________________________________________ | ||
| __________________________________________________________________ | ||
| Please seat me with members of (organization) ________________________ | ||
| I am unable to attend; my donation of $ ________ is enclosed. | TOTAL: $ ________ | |
| Mail this form with check made out to SpeakOut Illinois to: | SpeakOut Illinois 2009 c/o Illinois Right to Life Committee 65 E. Wacker Place, #800 Chicago, IL 60601 |
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