EFTA02698539

FESTIVAL OE CANNES HAITI Cagy/ilea ein/ C6api/05 A Gala For Haitian Relief Benefiting J/P Haitian Relief Organization, Artists for Peace and Justice, Happy Hearts Fund The Agora Pavilion at the Cannes International Film Festival Friday, May 18, 2012 - 9:30PM - TICKET/TABLE REGISTRATION FORM - Name (as it should appear on any printed materials) Company No listing please El Address City State/Country Zip/Postal Code Tel Fax Email I/We wish to reserve $100,000 MARDI GRAS - TABLE FOR 12 • 5 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh • Premiere placement in the room l/We wish to reserve $75,000 BAND MASKE - TABLE FOR 10 • 2 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh l/We wish to reserve $50,000 BAND A PIED - TABLE FOR 10 All table purchases will receive acknowledgement in the program as a category respective supporter. For inclusion in the program, tables must be purchased by May 8, 2012. l/We wish to reserve $7,500 BAND MASKE TICKET l/We wish to reserve $5,000 BAND A PIED TICKET I/We cannot attend, but would like to make a contribution in the amount of $ Please bill my: El Visa AmEx El MasterCard D Diners Club in the amount of US$ Credit Card Number Exp: Security Code: Signature If Corporate Card, Name of Company Bank Transfer: I am transferring funds in the amount of US$ to C. National Bank ABA # Sr credit to J/P Haitian Relief Organization -Account Checks. made payable to J/P HRO. m ailed to 6022 Wilshire 81vd, Suite 203, Los Angeles, CA 90036. For further inlormation, please call the RSVP Information lineal or email All tkkets are non-refundable. For U.S. residents. $350.00 of each ticket is a non-tax-deductible charge for food, beverage, an entertainment. Payments in excess of $350.00 per person and contributions in return for which no goods or services were received are tax deductible as a charitable contribution.Check. made payable to J/P HRO. J/P HRO Tax ID 27-17032371. Donations will be processed by J/P HRO and benefit all three organizations. Given limited ticket availability for this event, this form is intended only for the person to whom it was addressed and is non transferable. N 14111) I) Cwt GIORGIO ARNIAM WAfrati HAITIAN RELIEF ORGANIZATION ARTISTS `MACE JUSTICE 443) • Neckt-MC Please fax this form to r email regardless of payment method EFTA_R1_02059149 EFTA02698539