Honor Registration Form

Name:_________________________________

Address:  ____________________________________________________________________

City:  ________________________   State:_____      Zip Code: _________

Email: _______________________________              Phone:____________

Ticket Price is $75 (with a $10 discount for NJLGC/PLF members in good standing).  All tickets purchased after October 4, 2003 will cost $85. There will be a limit of one member-priced ticket for basic members (student, senior, single) and two member-priced tickets for premium memberships (couple, sponsor, etc.).

Note: We will NOT be issuing printed tickets in advance of the event. When you arrive, you will be directed to a check-in area, at which time you will be given a ticket and a table number (as long as you have pre-registered). There will be no tickets sold at the door.

Seating Preference (indicate with whom you wish to sit):________________

Additional Donation:
__ patron ($100)   __sponsor ($250)  __ benefactor ($500)  __ other [Amt:______]

Please indicate how you would like your name to appear in the Honor 2003 Program: _________________________________(patrons, sponsors, benefactors only) 

Enclose a check or money order payable to the Personal Liberty Fund for the amount indicated above, or use your credit card.

Credit Card Type: ________(Visa, MC, AMEX)         Card#:_________________________ 

Expires:__________       Total Amount:________   Signature:_______________________

Return to:  NJLGC/PLF, P.O. Box 11335, New Brunswick, NJ 08906-1335
Attn: Honor Committee   OR Fax to: (732) 249-5002