Reply Rorm GALA 2014

REPLY FORM

UNDER THE HONORARY PRESIDENCY OF

FRANÇOIS GAUDREAU
PRESIDENT – NETRICOM

THURSDAY, NOVEMBER 13, 2014
AT THE CHALET DU MONT-ROYAL

FROM 6:00 PM TO 10:00 PM

1196 Voie Camilien-Houde, Montreal, Quebec H3H 1A1

TICKETS & TABLES
Thank you for returning the duly completely reply form promptly!
PATRONS OF HONOUR
__ PATRON OF HONOUR ticket(s) at $1,000 each

$ _____________

__ Table(s) of 8 PATRONS OF HONOUR at $8,000 each

$ _____________

__ Table(s) of 10 PATRONS OF HONOUR at $10,000 each

$ _____________

SPECIAL MENTION DURING THE EVENING, SPECIAL SEAT(S), MEETING, PHOTOS AND RECEIPT FOR INCOME TAX PURPOSES OF $875 PER PERSON

ASSOCIATES
__ ASSOCIATE ticket(s) at $500 each

$ _____________

__ Table(s) of 8 ASSOCIATES at $4,000 each

$ _____________

__ Table(s) of 10 ASSOCIATES at $5,000 each

$ _____________

SPECIAL SEAT(S), PHOTOS AND RECEIPT FOR INCOME TAX PURPOSES OF $375 PER PERSON

FRIENDS
__ FRIEND tickets at $300 each

$ _____________

__ Table(s) of 8 FRIENDS at $2,400 each

$ _____________

__ Table(s) of 10 FRIENDS at $3,000 each

$ _____________

RECEIPT FOR INCOME TAX PURPOSES OF $175 PER PERSON
(SEE OVER)

REPLY FORM

DONATIONS
I cannot attend the event but wish to contribute to the discovery of new medical treatments by offering a $____________ donation.

FORM OF PAYMENT
GRAND TOTAL

$ __________________

(Tickets, Tables, Donations)

PAYMENT
Enclosed please find a cheque for $ ________________________ to the order of Marie-Robert NeuroTrauma Foundation
Please debit $ _____________________________ from

VISA

Card number: _____________________________________________________

MASTERCARD
Expiry date: ______ /______

In the name of: __________________________________________________

PAYMENT CATEGORY

COMPANY

RECEIPT FOR INCOME TAX PURPOSES

INDIVIDUAL
YES

IF INDIVIDUAL, please enter your personal contact information.

NO

Name: __________________________________________________________________________________________________
Position: _______________________________________________________________________________________________
Company: ______________________________________________________________________________________________
Address: ________________________________________________________________________________________________
City: _________________________________________________________ Postal code: ______________________________
Telephone: _________________________________________ Fax: _______________________________________________
E-mail: _________________________________________________________________________________________________
Resource person: _________________________________________________________________________________________

NOTE: You may bid on attractive items at the silent and open outcry auctions to be held there!

PLEASE RETURN THE DULY COMPLETED REPLY FORM TO:
Marie-Robert NeuroTrauma Foundation
6450 Notre-Dame Street West, Suite 200, Montreal, Quebec H4C 1V4
Tel.: 514 932-2662 - Fax: 514 932-1358 - Toll-free: 877 702-2662
fondationneurotrauma@bellnet.ca
www.fondationneurotrauma.ca