BCSA Rescue Benefit Dinner and Night of Entertainment
Reservation Form
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NAME:
ADDRESS:
CITY/STATE/ZIP:

TELEPHONE:
E-MAIL:   
CONFIRM E-MAIL:   
CHECK ONE: Dine In    Take Out
NO GUESTS: @ $15 each =

 

SIGNATURE: _________________________________________    DATE:

 RESERVATION DEADLINE: 9/1/05

Send check payable to BCSA with reservation to:
Wayne Koutsky, N55 W 15320 Northway Dr. , Menomonee Falls, WI 53051
Questions: Contact Myra Westphal
Office Use Only: Received _______________________  Check #: _____