Name  ________________________________________________________________________________________
 

Representing ___________________________________________________________________________________
 

Address ______________________________________________________________________________________
 

City/State/Zip __________________________________________________________________________________
 

Phone (_____)_____________________________________
 
List foursome below (if any)

1. _________________________________________

2. _________________________________________
 
3. _________________________________________

4. _________________________________________
 

FEE	We have a prize(s) to donate  Please call: _________________________

 

 _____ Golfers   at $  85.00 = _________
 

 _____ Dinner Only  at $  25.00 = _________
 

 _____ Tee Box Sponsor at $200.00 = _________
 

                         Total Due   =  _________
 

Make checks payable to:  Minnesota Council On Compulsive Gambling (a 501 (c) (3) organization).
 
Return to:  ACM, PO Box 131462, Roseville, MN 55113-0013