2019 Tribute Order Form

2019 Tribute Order Form 44th Annual Delta Invitational Tournament │ American Cancer Society Benefit │Saturday, May 4th, 2019 at Indianola Country Club □ Yes. I am a cancer survivor; I would like to be recognized as a cancer survivor at the 2019 DIT with the purchase of a luminary. □ Yes. I am a cancer survivor; I would NOT like to be recognized as a cancer survivor at the 2019 DIT. __________________________________________________________ First/Last Name

o o o o

Luminaries are available ($10.00 each) to honor the memory of a loved one, celebrate one’s survivorship or simply recognize their courage in fighting cancer. Please list the names and contact information of loved ones or friends you would like to recognize. Luminaries displaying those names will adorn the Country Club the evening of the Dinner & Dance. Please mail this form with your check made payable to American Cancer Society to: Planters Bank, Attn: Leah Keith P.O. Box 31, Indianola, MS 38751

___________________________________________________________________________________________________________________________ (Purchase of Additional Luminaries)

First Name

Last Name

Given by (First/Last Name or Family Name)

In MEMORY of Address of Family

______________________________________ ______________________________________

____________________________________

In MEMORY of Address of Family

______________________________________ ______________________________________

____________________________________

First Name

Last Name

Given by (First/Last Name or Family Name)

In HONOR of Address of Family

______________________________________ ______________________________________

____________________________________

In HONOR of Address of Family

______________________________________ ______________________________________

____________________________________

_____ TOTAL Tributes Purchased

Your Name __________________________________________ Phone # __________________

_____ TOTAL Amount Purchased ($10 each)

Address

_____________________________________________________________________