_____________________________________________
First
Name:
Last Name:
______________________________________________________________
Company/individual Name as it should appear:
_____________________________________________
Billing Address:
_____________________________________________
City: State:
Zip:
_____________________________________________
Phone Number:
E-Mail address:
Please Check if you want to sponsor a
hole:
Or co-sponsor a hole:
Total Amount enclosed $_____________
Return to:
Child Protection Center
138 Marietta Rd., Suite E
(740) 779-7431
Fax (740) 779-7432