2019REUNIONREGISTRATION

PRINT THIS FORM, FILL IT OUT AND SEND IT TO:

The Survivors c/o Karen DeWall

3979 Bridle Path Loop,

Pinetop, AZ 85935

Yes, I'll be attending the Media and Advertising Survivors Annual Reunion, Saturday,

Oct. 16, 2021, 11:30am at the University Club of Phoenix.

List yourself, those coming with you, and meal choice of chicken or salmon.

Name____________________________________________Chicken___Salmon___

Enclose a check to The Survivors for a total of $30 times the number of your attendees.

The name above will be what we use for your name tag.

Thank you, and we look forward to seeing you!!

To keep our records up to date for future contact, please give us your current information. (We never share this with anyone)

Name_______________________________________________

Address_____________________________________________

City____________________State________Zip______________

e-mail address:________________________________________