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Century Club Grubstake Breakfast®

Ritz Carlton Hotel - Tysons Blvd., McLean
7:45 - 9:30 a.m.

YES! Sign me up for the Century Club Grubstake Breakfast. I understand the cost of attending is $75 per person ($45 per Century Club member/GMU Partner) payable in advance. $10 additional fee for payment received within 2 days prior to the breakfast date. RESERVATIONS ARE REQUIRED!! (Two day written cancellation required. All no-shows or late cancellations will be billed!) Please complete separate forms for guests.

Date of Breakfast:
Name:
Title:
Organization:
Address:
City:    State:    Zip:
Phone:    FAX:
E-mail:

I heard about this program from
I am am not a qualified investor for this program.

____ MasterCard ____ Visa      ___American Express

Card Number ______________________________________ Exp. Date __________________

Signature ___________________________________________________________________

INSTRUCTIONS:
If you wish to PAY BY CREDIT CARD, please complete, print and FAX form with Master Card/VISA/American Express number handwritten on the form to (703) 993-4760. Your payment must be received 2 days prior to the breakfast date or you will be charged an additional $10 at the door. (American Express is not accepted.)

If you wish to PAY BY CHECK, please complete, print and mail a copy of the form with your check to the Century Club Office. Your payment must be received 2 days prior to the breakfast date or you will be charged an additional $10 at the door.

(PLEASE print this form before electronic submission)

Make checks payable to Century Club of GMU
Century Club of George Mason University, Inc.®
MSN 1D7 Fairfax, VA 22030
703-993-4765 fax 703-993-4760
e-mail: