"BUY A MOVIE SEAT" CAMPAIGN
ORDER FORM

NAME    ____________________________________________________________________

ADDRESS ____________________________________________________________________

        ____________________________________________________________________

CITY    ___________________________________  STATE _____   ZIP _____________

PHONE   ____________________________________________________________________

E-MAIL  ____________________________________________________________________


IF PAYING BY CREDIT CARD:

CREDIT CARD     ___ VISA     ___ MASTER CARD     ___ DISCOVER

CARD NUMBER     ______________________________________ EXP. DATE ___________  
(If paying by credit card, please include CREDIT CARD BILLING address above)


Purchase Choice(s):

___ Single Theater Seat - $150
___ Row of (4) Theater Seats - $500
___ Booth in the Alumni Hall Cafe - $1000
___ I just want to make a donation (any amount)



Dedication Plate Choice(s):

___ Option # 1       Line 1: Dedicated To
                     Line 2: __________________________________ 

___ Option # 2       Line 1: BHEC Alumni Sponsor
                     Line 2: __________________________________ 

___ Option # 3       Line 1: In Memory Of
                     Line 2: __________________________________

___ Option # 4       Line 1: __________________________________