Houston 1960 Chapter
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Northwest Forest Conference Center
12715 Telge Road, Cypress TX 77429
Thursday September 25, 2008
6:30 p.m. to 10:30 p.m.
PREMIUM PARTNERSHIP ORDER FORM
Date: _____________
Company Name: ________________________________________Business Type:__________________
Contact Name: ________________________________________________________________________
Address: _____________________________________________________________________________
City: ____________________________________________ State: ___________ Zip: _______________
Company Phone: ____________________________Contact Phone: ______________________________
Email: ____________________________________ Web Site: __________________________________
PAYMENT: CIRCLE ONE CHECK
MASTERCARD
VISA
AMEX
Card #_______________________________
Expire _________________________________
Name on Card (Please print) _______________________________________________________
____________________________________
Total to be Charged $ _____________________
Signature
Please check the Partnership Level you agree to purchase:
_______ CHAMPAGNE PARTNER
(1)
$4000
_______ TEXAS HOLD ‘EM PARTNER
(2)
$2500
_______ BLACK VELVET PARTNER (2) $1000
_______ WHITE SATIN PARTNER (2) $1000
___NA_ ROULETTE
(1) $500 Committed!
___NA_ CRAPS TABLE (2) $500 Committed!
_______ BLACK JACK TABLE (10