Rockland Family Shelter
6th Annual Distinguished Citizen Award Dinner
Saturday, April 17, 2004

To have your name or your business's name appear as a contributor to the Rockland Family Shelter in our special Journal for this event, please enter your information below. The Journal is distributed to each attendee at the Distinguished Citizen Award Dinner.

If you would like to attend the dinner please click here for more information.

Kindly respond before March 22, 2004.

Instructions:

Please complete the form below. All fields are required. When you press the submit button you will be brought to a secure server to enter your credit card information. After the donation process is complete you will receive an e-mail confirmation and you will receive an ackowledgement for tax purposes. Thank you so much for your support.

	Rockland Family Shelter 6th Annual Distinguished Citizen Award Dinner Journal Select Category under which your name will appear $10,000 Gift $5,000 Gift $1,000 Gift $500 Gift $300 Gift $150 Gift $50 Gift $25 Gift Full Name Address City State <select state here> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Telephone E-Mail