2014 Liberty Place Holiday Tea
REGISTRATION FORM
PURCHASING TICKETS (Tickets are $25/each) There are 144 available tickets.

________ individual ticket(s) x $25.00 =
$ ____________

________ reserved table(s) of eight x $200.00 =
$____________

I am unable to attend. However I would like to donate
$____________
Total amount enclosed
$ ____________
Name: _______________________________________________________________________________________
Address: ______________________________________________________________________________________
City, State, and Zip Code _________________________________________________________________________
Phone/Fax:____________________________________________________________________________________
Email address: _________________________________________________________________________________
Please make checks payable to Liberty Place Recovery Center for Women.
ALL DONATIONS ARE TAX-DEDUCTIBLE.
TO PAY USING A CREDIT CARD (VISA AND MASTERCARD ONLY)
CREDIT CARD #: ________________________________________________________________________________
3-DIGIT CODE:_________________________________________________________________________________
EXPIRATION DATE:______________________________________________________________________________
SIGNATURE:___________________________________________________________________________________
Please mail completed form and your check to:
Liberty Place, Attn: Gwen Holder, 218 Lake Street, Richmond, KY 40475.
Please call Gwen Holder at 859/625-0104 (press 5) for additional event information.
Tickets will be mailed to those who reserve by October 31st. All other tickets will be held at the door.
All proceeds and donations for and at this event will go to support Liberty Place Recovery Center for Women.