Name:____________________________ Date:___________________
Address:___________________________________________________
City:_________________ State____ Zip Code____________
Phone #:________________________
Email Address:____________________________________________
Members and Guests Attending
Title Name Det. Name/# or MCLA or Guest Arriving?
____ _________________ __________________________ Fri/Sat
____ _________________ __________________________ Fri/Sat
____ _________________ __________________________ Fri/Sat
MCL Member/MCLA Registration __ x $ 10.00 = $________
Banquet Saturday Night, April 28th __ x $ 25.00 = $_________
Total Payment $_________
(Meal is $25.00 per person) Please check your meal choice:
(Chicken) X______ (Steak) X______ ______________________________________________________________________________ Please return this form by April 5th, 2012 to:
Commiskey-Wheat Detachment No. 1073
P.O. Box 18290 • Hattiesburg, MS 39404
and make check or money order payable to Commiskey-Wheat Detachment No. 1073.
For help or additional information, contact Clifton Addison at 601-606-4336/e-mai:
clifton_addison@nordansmith.com;
or Patrick Tutor at 662-488-5952.
We will send you an e-mail (or postcard) to confirm your banquet reservation.