Blue Moon Hon Com Rsvp Form

Honorary Committee Reservation Form □ Yes! I/We will join the Honorary Committee at the level of $200 per person. Please list my/our name(s) in the invitation and online media as follows: _______________________________________________________________________ (Name as you wish it to appear in all event materials) EVENT COMMITTEE (in formation) Colleen Ryan Co-Chair Penny Vavura Co-Chair Christopher Burke Mark Duffy Albert Gnidica Sheila Healy Mary Alice Molgard Mark Mulson Richard Nacy Brian Palazzolo Carl Roberts-Alexandrov Eve Ryan Nicole Stein Frances Tarlton

Please return this form by October 21, 2009 to: AIDS Council of Northeastern New York 927 Broadway Albany, NY 12207 Attn: Once in a Blue Moon Gala

Thank you for supporting the AIDS Council of Northeastern New York!

□ Yes! I/We would like to be a Table Captain, and reserve a table of 10 seats at the Honorary Committee level of $200 per person for a total of $2,000. Please list my/our name(s) in the invitation and online media as follows: _______________________________________________________________________ (Please list names of those at your table – ten total – on the reverse as they should appear in event materials.)

□ My company will join the Corporate Honorary Committee at the level indicated below. Corporate Honorary Committee members receive one Honorary Committee ticket to the event as well as the company name listed in the event invitation and online media.

□ $500

□ $1,000

□ $1,500

□ $2,500

Please list my company in the invitation and online media as follows: _______________________________________________________________________ (Company name as you wish it to appear in event materials.)

□ We are unable to join the Honorary Committee, but would like to make a $ ........................ donation to the AIDS Council. Please select your method of payment: □ Check enclosed. Make checks payable to the AIDS Council of Northeastern New York.

□ Credit Card - Please charge my MasterCard ● Visa ● American Express (circle one). Amount to be charged: $_______________ Name as it appears on card: ................................................................................................. Account #:......................................................................

Expiration Date: ........................

Signature: ............................................................................................................................. Do we have your correct contact information? If not, please fill in below. Mailing Address: .................................................................................................................... City, State & ZIP: .................................................................................................................. Home Phone #: .......................................... Work Phone #: .............................................. E-mail Address: ....................................................................................................................