AUCTION GALA JOURNAL FORM Saturday, April 1, 2017 Name / Company: _____________________________________________________________________________________________________________ Contact Person: _______________________________
Make checks payable to Portledge School and mail along with this form to: Portledge School, Development Office 355 Duck Pond Road Locust Valley, NY 11560
Rate
Dimmensions
JOURNAL DEADLINE IS MARCH 10, 2017 £ Please bill my Student Account. Name: __________________________ Parent Signature: _____________________ ____ £ Enclosed is my/our check made payable to Portledge School for $ ___________________________________________ £ Please charge my credit card. £ Visa £ Mastercard £ American Express Card Number: ____________________________________________________
Exp. Date: ________/_____________
Name as it appears on card: _________________________________________________________________________ Signature: ___________________________________________________________________________________________
Tax I. D. # 11-6044973 - Thank you for your support. 355 Duck Pond Road, Locust Valley, NY 11560