Payment Information

November 21, 2010 Screening and Reception with

Connie Francis
In support of Brad Rosenblatt for Coral Gables City Commission
Please choose your Screening and Reception: (Check Option 1 or Option 2)
Option 1 Option 2
First Screening 12:15 - 2:00 PM Reception 2:00 - 3:00 PM
Reception 2:00 - 3:00 PM Second Screening 3:00 - 4:30 PM

Your Information: (Please print clearly)

Name:
Company:
Address:
City: State/Zip:
Email: Telephone:
Tickets for the screening of “Where the Boys Are” and the Private Reception Hosted by Connie
Francis are a MINIMUM of $85.00. Additional contributions in support of Brad Rosenblatt for
Coral Gables City Commission, Group 4 are welcome.
#___________ Ticket(s) @ $85 per person
Yes, I would like to support Brad Rosenblatt for Coral Gables City Commission with an
additional donation of $_____. (Maximum contribution is $500.00 per person or entity)
If purchasing more than one ticket, please list guest(s) name(s) below:

Payment By Check: Payment By Credit Card:

Make checks payable to: Please Charge my Credit Card for $
Campaign to Elect Brad Rosenblatt Visa MasterCard AMEX
Name on card:
Please mail this form and your check to:
Credit Card #:
Campaign to Elect Brad Rosenblatt
Security Code # (required):
2700 Ponce de Leon Blvd.
Exp. Date:
Coral Gables, FL 33134
Signature:
Profession of Individual Paying: Please fax back to 305-448-8453
Profession of Individual Paying:

MAXIMUM CONTRIBUTION $500 PER PERSON OR ENTITY

Personal, business, and corporate checks allowed. Checks payable to “Campaign to
Elect Brad Rosenblatt.” The purchase of a ticket for, or a contribution to, the campaign
fundraiser is a contribution to the Campaign to Elect Brad Rosenblatt.

Political advertisement paid for and approved by Brad Rosenblatt for Coral Gables City
Commission, Group 4.