EFTA00296192.pdf

REGISTRATION FORM amfAR Cinema Against AIDS 22 to benefit amfAR, The Foundation for AIDS Research THURSDAY, MAY 21, 2015 Hotel du Cap-Eden-Roc, Cap d'Antibes, France FOR ALL PAYMENT METHODS, PLEASE EMAIL OR FAX THIS FORM TO e: CinemaAgainstAIDStoamfar.org f: +1.917.591.8156 Name (as it should appear on printed materials) Company Address City State/Country_ Zip/Postal Code Telephone__ ax _ E-mail (required)_ J No listing please. FOR INFORMATION ON CORPORATE SPONSORSHIP PACKAGES, PLEASE CONTACT ANDREW BOOSE AT OR • l/We wish to reserve GRAND PHILANTHROPIST PACKAGE(S) a' $275.000 (prime. first choice dinner seating for 12 guests, Co•Chair listing for one in,: . i2nt program) • l/We wish to reserve GRAND BENEFACTOR PACKAGE(S) at $200,000 (premium dinner seating for 10 guests. Vice Chair listing for one individual in event program) • l/We wish to reserve BENEFACTOR PACKAGE(S) at $150,000 (profaned dinner seating for 10 guests. -Benefactor" listing in event program) • l/We wish to reserve a BENEFACTOR "PAIR" at $60,000 (prime dinner seating for two guests, "Benefactor" listing in event program. Vice-Chair listing for one individual in event program) • !Me wish to reserve PATRON TICKETS) at $20,000 (profaned dinner seating. "Patron" listing in event program) • IM/e wish to reserve _ SUPPORTER TICKET(S) at $15,000 (dinner seating. "Supporter" listing in event program) • Me cannot attend, but would like to make a contribution to amfAR in the amount of US$__ Prices subject to change. If you'd like to reserve, please call to confirm pricing and availability. Grand Benefactor and Benefactor Packages can accommodate up to 12 guests at an additional cost, for more information please contact Christina Christofi. • A check made payable to amfAR in the amount of US$ ___is enclosed. • I am transferring funds in the amount of US$ to Bank of America / 100 West 33rd Street / New York. NY 10001/ USA / for credit to The Foundation for AIDS Research (Concentration Account)/ ABA IS 0260-0959-3 / Account IS 009427761547 / Swift Code: BOFAUS3N • Please bill my 0 AmEx K Visa 0 MasterCard K Discover in the amount of US$ Credit Card Number Expiration date SEC Signature__ If corporate card. name of company_ amfAR MAKING AIDS HISTORY Checks made payable to amfAR may be mailed to amfAR/Cinema Against AIDS, 120 Wall Street, 13th Floor. New York. NY 10005. For further information. please contact Christina Christofi at CinemaAgainstAIDSOamfar.org or +1.212.806.1611. All tickets are non-refundable. For U.S. residents, $500 of each ticket Is a non-tax-deductible charge for food, beverage, and entertainment. Payments in excess of $500 per person and contributions in return for which no goods or services were received are tax deductible as a charitable contribution (amfAR's Tax ID 13-3163817). EFTA00296192