Feed Your Inner Einstein Royal Canadian Institute for the Advancement of Science Gala Dinner - April 25, 2013 Name:__________________________________________________________________ Organization:_____________________________________________________________ Contact_________________________________________________________________ Phone:__________________________________________________________________ Email___________________________________________________________________ Address:________________________________________________________________ Address:________________________________________________________________ Please bill me for: _________ Tickets at $250 _________ $1,800 Four Ticket Package with Name recognition in the program _________ $5,000 Silver Partnership _________ $10,000 Gold Partnership _________ $20,000 Platinum Partnership Yes/no Send me the list of table hosts I want to pick my own Yes/no Surprise me and assign me to a table Yes/no Upon Request a charitable receipt will be issued, less the cost of dinner and Beverages Yes/no Send an invoice Yes/no Charge my Visa or Master Card Card Number____________________________________expiry ______ For further information contact Kathy Carter at phone: 416-962-7314 fax: 416-962-7314 e-mail: royalcanadianinstitute@sympatico.ca web: http://www.royalcanadianinstitute.org

Feed Your Inner Einstein

Royal Canadian Institute for the Advancement of Science

Gala Dinner - April 25, 2013

Name:__________________________________________________________________

Organization:_____________________________________________________________

Contact_________________________________________________________________

Phone:__________________________________________________________________

Email___________________________________________________________________

Address:________________________________________________________________

Please bill me for:

_________ Tickets at $250

_________ $1,800 Four Ticket Package with Name recognition in the program

_________ $5,000 Silver Partnership

_________ $10,000 Gold Partnership

_________ $20,000 Platinum Partnership

Yes/no Send me the list of table hosts I want to pick my own

Yes/no Surprise me and assign me to a table

Yes/no Upon Request a charitable receipt will be issued, less the cost of dinner and

Beverages

Yes/no Send an invoice

Yes/no Charge my Visa or Master Card

Card Number____________________________________expiry ______

For further information contact Kathy Carter at phone: 416-962-7314 fax: 416-962-7314