Friends Foundation Black Tie Gala 
benefitting Ste. Genevieve County Memorial Hospital

 
Sponsorship Levels:

Table of 10 - $1,000.00

Bronze Sponsorship - $1,500.00

Silver Sponsorship - $2,000.00

Gold Sponsorship - $2,500.00

Platinum Sponsorship - $5,000.00

Diamond Sponsorship - $7,500.00/cart

Date: 03/29/24
 
Table of 10 - $1000: Quantity
Bronze Sponsorship - $1500: Quantity
Silver Sponsorship - $2000: Quantity
Gold Sponsorship - $2500: Quantity
Platinum Sponsorship - $5000: Quantity
Diamond Sponsorship - $7500: Quantity
Total Charge: $
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing City:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
   
Additional Contact Information:
Phone Number:
Email Address:
Email Address (to confirm):
Additional Comments