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 The Southern Flames present  Leah Fairbanks Lottery Form

 Name:                                                                                                              

Address:                                                                                                          

                                                                                                                       

Telephone:                                                                                                       

Alternate Telephone (mobile):                                                                           

Email Address:                                                                                                 

 Leah Fairbanks Class Preference (only check one):

              Only able to attend March  10 & 11, 2005 (Thursday / Friday) 

              Only able to attend March 12 &  13, 2005 (Saturday / Sunday) 

              Can attend either session, prefer Thur/Fri – You may be placed in either class.

              Can attend either session, prefer Sat/Sun – You may be placed in either class.

 Do you want to be on the waiting list if your name is not drawn for a class session (circle one)?  yes    no

 Please print out and complete this form.  You can either drop this form and your check off at the Wednesday, January 19, Southern Flames meeting, or you can mail the completed form and your check in the amount of $315.00 made payable to “Southern Flames” to:

Southern Flames

311 Peachtree Hills Avenue, Suite. 11A

Atlanta, GA  30305

NOTE:  CHECKS AND FORMS MUST BE RECEIVED BY JANUARY 14, 2004

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For Southern Flames Administrative Use Only

Received On _________   Check # __________

 

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