David Hersey Fund-Raiser Registration

Name: __________________________________________________________

Address: _________________________________________________________

Phone Number: ___________________________________________________

Number of raffle tickets ($20/each):____________________________________

Number of event tickets ($75/each):____________________________________

T-shirt size:______________ E-mail address:____________________________

Please make check payable to: SkyVenture New Hampshire and mail to:

David Hersey c/o SkyVenture New Hampshire 3 Poisson Avenue Nashua, NH 03060

Or to Charge By Phone, call toll-free 877-522-2522 (Visa / Master Card accepted)

For more information or to donate an item to the raffle,

please call Josh Wolfe: 978-838-9476 or SkyVentureNH: 603-897-0002