Contact Name_____________________________________
Phone_______________________________
Company_________________________________________
Fax_________________________________
Address______________________________________
State _____________ Zip__________________
*E-mail___________________________________________
Sponsorship Level:____________________________________________
£
Check enclosed (payable to TIP)
£
MC
or
£
Visa
#_________________________________
Exp. Date_____________
Amount $__________
Name on Card_______________________________________
Signature_____________________________