Insurance Club Mixer 2006

Reservation Form

2006 UNT Industry-Student Mixer at Dave and Buster's, March 2, 2006 from 3:00 to 7:00 p.m.

Guest Name (as you would like it on your name tag)	Job Title
Name:
Employer:
Address:
Address line 2:
Phone:
FAX:
Email:
I / we will be there! I can't be there, but I am sending a donation to sponsor student attendance!
Pay by $75 per person OR $200 for 3 people (and $50 for each additional guest) Payment must be arranged separately, as detailed on the next page.