Casino Night – Tickets Name and Email * First Name Last Name * Last Name (and Credentials) Email Address * Email Address Street Address * Street Address 2 City * State * Ohio Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Phone Number * Name for Badge * Please include any credentials that you would like to have on your name badge (MD, DO, FAAP, MPH, etc.). Number of Casino Night Tickets - Tax Deductible Donation of $45 per ticket One - $60 Two - $100 Three - $160 Four - $200 Five - $260 Six - $300 Seven - $360 Eight - $400 Nine - $460 Ten - $500 New for 2014! Bring along your friends, family, or coworkers and receive a discount for every other ticket that you purchase! (Ticket #1 -$60, #2 - $40, #3 - $60, #4 - $40, etc.) Name(s) of Casino Night Attendees I would like to make an additional donation of ________ to the Ohio AAP Foundation. Total Due:
