7th Annual Black & White Dance Party 2012 - Registration

Please fill out the form below to register for the Dance Party 2012

7^th Annual Gala
BLACK & WHITE
DANCE PARTY

Saturday, March 31, 2012

REGISTRATION FORM

Name*	(required)
Address*	(required)
City*	(required)
Telephone*	(required)
Fax
E-mail*	(required)

TICKET PRICE (CAD) : $225 EACH	Number of Tickets Required
DONATION (CAD) $ (With Tax Receipt)

METHOD OF PAYMENT:
1. CHECK PAYABLE TO: THORACIC SURGERY Research Foundation of Montreal 1560, rue Sherbrooke est, Pavillon Lachapelle, Suite D-8051 Montréal (Québec) H2L 4M1 Registration #: 85697 2872 RR0001	2. PAY BY CREDIT CARD: VISA MASTER CARD


For further information please contact Andrée Prud'homme at (514) 890-8000 extension 24543