Contact Name:

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Name of Company or Individual to be recognized:

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Address:

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Phone:

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Fax:

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Email:

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Please charge my:

_____ VISA

_____ MASTERCARD

_____ AMERICAN EXPRESS

Name on the card:

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Card Number:

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Expiration Date:

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Print and mail this page, along with your credit card information or a check payable to Burnsville Rotary Club, immediately to:

Burnsville Rotary Club
P.O. Box 1346
Burnsville, MN 55337

If you have any questions, please contact:
Jim Schmitt at schmittmn@comcast.net
or Dick Manley at dickm@ondemandgroup.com