2004 AAPD LEADERSHIP GALA
Ticket Purchase Form

You may order your tickets by phone by calling either 703-556-4245 (Voice) or 703-556-0448 (TTY), or by mail by using this form to the address provided at the bottom of the form:

Name____________________________________________________________

Title______________________________________________________________

Company Name____________________________________________________

Address__________________________________________________________

City_______________________________ State_______ Zip________________

Phone___________________________ Fax_____________________________

e-mail____________________________________________________________

I would like to purchase _______ tickets at $85 per ticket.

In addition to purchasing tickets, I would like to make a contribution of $________

I/we cannot attend, but wish to make a contribution of $ ____________________

Total Payment: $___________________________________________________

Please charge my:

____MasterCard ____Visa ____Discover ____American Express

Account name_____________________________________________________

Account number_______________________________ exp. date_____________

Authorized signature________________________________________________

If you are purchasing more than one ticket, below please provide the names of your guests:
_________________________________________________________________

_________________________________________________________________

Please reply by March 1, 2004.

Print out this form, make checks payable to AAPD,
and return payment with form to:
AAPD
c/o Hayes & Associates
1320 Old Chain Bridge Road, Suite 300
McLean, VA 22101