RSVP (please Print & mail) 

Steffens Scleroderma Research Foundation

PO Box 38037, Albany, NY  12203

Name                                                                                             

Phone                                  Email                                                 

     Check Enclosed (Payable to Steffens Scleroderma Foundation)

    Please charge my Amex, Discover, MasterCard, Visa

       Card #                                                        Exp date                .

       3-4 digit code (CVC code)                    

Name (as it appears on card)                                                   

Billing Address                                                                             

Authorized Signature                                                                  

___  I would like to reserve _____ number seats at $150/person

____  I would like to be a member of the Honorary Committee at $225/person or _____ $400/couple

___   I would like to reserve _____ table(s) of 10 for $1,250 per table

____   I'm all about that jazz & love to support the foundation, but can't commit to the whole evening.             Cocktail hour only (6-7pm) $125/ per person

___   I am unable to attend, but please accept my tax-deductible donation of $                    

Please indicate each guest's entrée choice

Name(s)                                            Choice of Entree

______________________________  Chicken   _____  Beef     _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian 

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian 

 

______________________________  Chicken   _____  Beef    _____Fish   _____  Vegetarian 

 

                Total amount $                         

Additional Sponsorship levels upon request

For more information, please call (518) 573-0259

click here for online payment

(Please include relevant information such as names, ticket & meal choices in the comment section)