Registration Form


2011 GOLF TOURNAMENT

ONLINE REGISTRATION

To register online, please fill in the following form.
Please fax this information to 623-243-6580 or mail to:
Arizona Myeloma Network (AzMN)
20280 N. 59th Ave. Suite 115 #448
Glendale, AZ 85308

 

Please fill out the form below: 

Company Name (If Applicable)

Contact Name (required)

Address (required)

City, State, Zip (required)

       

Phone Number (required)

Email Address

   
Player 1 Name  Handicap/Avg. Score   Phone #
Player 2 Name  Handicap/Avg. Score   Phone #
Player 2 Name  Handicap/Avg. Score   Phone #
Player 4 Name  Handicap/Avg. Score   Phone #


Foursome: $600, Single: $160
(Includes Continental Breakfast and Lunch)
Non-Golfers Lunch: $35 per person
(reservations required)

 

Note: On receipt of your Registration, Arizona Myeloma Network will contact you by phone for credit card payment information.

I am unable to participate. Please accept my deductible contribution of $ payable by PayPal at email address JackKavanagh@cox.net.

Contributions to the Arizona Myeloma Network (AzMN) benefit Multiple Myeloma patients and their families and caregivers.

    Individuals Check Here:  Please register me as an individual player for the tournament.

Additional Information


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This form will be emailed to the Arizona Myeloma Network.  All information submitted in this form is kept private and the personal information you supply to Arizona Myeloma Network (AzMN) will not be given, sold, rented, loaned, or otherwise disclosed to any third parties outside of Arizona Myeloma Network (AzMN), except when we have your permission or under special circumstances, such as when we believe in good faith that disclosure is reasonably necessary to (i) comply with legal process, (ii) enforce the Terms of Use, (iii) respond to claims that any content on Arizona Myeloma Network (AzMN) violates the rights of third parties, or (iv) protect the rights, property, or personal safety of Arizona Myeloma Network (AzMN), its users, or the public.