Restaurant Name
Website Address
Restaurant Street Address City AL AK AR AZ CA CO CT DE DC FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY State ZIP
Mailing Address City AL AK AR AZ CA CO CT DE DC FL GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY State ZIP
Email Phone Fax
SYSCO Customer #
How did you hear about us? please pick one Special Olympics Oregon Representative SYSCO Representative Family,Friend or Colleague Newspaper Magazine Radio Television Transit (Outdoor) Participating Restaurant in Town Special Olympics Oregon Website or e-Newsletter Dine Out for Greatness Website ORA Website SYSCO Website or e-Newsletter Other Website
We will contribute % of August 7th, 2008 proceeds.
-or-
We will contribute a flat amount of $ .00 Note: Minimum suggested donation is $250
Name of your local newspaper
Your signature (initials only) Title
Today's date (00/00/08)
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