Organization Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name *

First Name

Last Name

Contact Phone Number *

(###)

###

####

1st Choice of Event Date (Mon, Tues or Wed) *

MM

DD

YYYY

2nd Choice of Event Date (Mon, Tues or Wed) *

MM

DD

YYYY

3rd Choice of Event Date (Mon, Tues or Wed) *

MM

DD

YYYY

Please check boxes below, to indicate you agree to our terms: * *

I have read and understand WAB's "Dining for a Cause" Guidelines and understand that the success of this program requires work on our organization's part in promoting the event.

I understand that if anyone is soliciting during the event, the WAB reserves the right to null and void this agreement of providing 15% of "Dining for a Cause" sales to your organization.

Contact Signature *

First Name

Last Name

Signature Date *

MM

DD

YYYY