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| Benefactor ** | (6 memberships) $350 | $ ________ |
| Sponsor ** | (4 memberships) $175 | $ ________ |
| Patron ** | (2 memberships) $100 | $ ________ |
| Friend ** | $50 each X ______ | $ ________ |
| Adult | $35 each X ______ | $ ________ |
| Student | $10 each X ______ | $ ________ |
| Family Patron ** | $110 (2 adults + children living at home) | $ ________ |
| No. of children's tickets needed _____ | ||
| Family | $80 (2 adults + children living at home) | $ ________ |
| No. of children's tickets needed _____ | ||
a selected concert. (An added value for the categories marked with "**".) |
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| Name | ____________________________________ |
| Address | ____________________________________ |
| City/State | ______________________ ZIP __________ |
| Telephone | ( ____ ) ___________ |
| Check Enclosed (Make check payable to "Hartsville-Coker Concert Association") | ||
| Charge my Visa MasterCard | Expiration Date _____ Card # ____________________ | |
| Name on Card ________________________ | Signature _____________________________ | |