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FORM FOR PAYMENT BY CHECK
FILL OUT, (NOTE * REQUIRED)

PRINT FORM
THEN CLICK "SUBMIT"

MAIL FORM & CHECK T0:

Rodney A. Mann
902 Oak Park Drive
Shelbyville IN 46178

CHECKS PAYABLE (IN U.S. FUNDS) TO:

Knights Templar 67th Triennial Corporation

CHECK MUST BE RECEIVED BY JUNE 1, 2018

*LAST NAME
*FIRST NAME, MIDDLE INITIAL
Lady's/Guest's Name
*TITLE
*Jurisdiction
Voting Delegate (Yes/No) ANSWER here or below!!!
Non-Voting Delegate (Yes/No)
*Address
*City/State/Zip
*Arrival date & time
*Departure date & time
*HOME PHONE
CELL PHONE
*E-Mail Address:
*REGISTRATION FEE -$275.00
LATE REGISTRATION FEE after June 1, 2018 = $25
ADDITIONAL TICKETS - Grand Master's Desert/Cocktail Reception - $55.00 each
Sunday Tour of the Indianapolis 500 Track -$55.00 each
Monday's Ladies Luncheon- $38.00 per person
ADDITIONAL TICKETS - Grand Master's Banquet/Entertainment - $75.00 each
Roasted Pork Loin #
Hazelnut Crusted Salmon #
Vegetarian #
*TOTAL COST
TOTAL AMT TO BE RECEIVED BY CHECK NO LATER THAN 1 JUNE $$$$
PRINT COPY FOR MAILING WITH CHECK - NOW!!