First Name:                  Middle:   Last: 

eMail Address:            

Work Phone:                 Home Phone:  Cell Phone:

Preferred method of contact:  Work Phone Home Phone Cell Phone eMail Mail Doesn't Matter

When do you want to run the fundraiser?  Month: January February March April May June July August September October November December     Year: 2008 2009 2010

Name of Organization: 

Street Address:           

City: 

State:  KY IN Other

Zip Code:

How many fundraisers does your group run each year? 

Would you be interested in receiving a Butter Braid^® sample if you are eligible? Yes No Undecided

Comments:                

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