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2019 Tribute Order Form

44th Annual Delta Invitational Tournament │ American Cancer Society Benefit │Saturday, May 4th, 2019 at Indianola Country Club

□ Yes. I am a cancer survivor; I would like to be recognized as a cancer survivor at the 2019 DIT with the purchase of a luminary.
□ Yes. I am a cancer survivor; I would NOT like to be recognized as a cancer survivor at the 2019 DIT.

__________________________________________________________
First/Last Name

o Luminaries are available ($10.00 each) to honor the memory of a loved one, celebrate one’s survivorship or simply recognize their courage in fighting cancer.
o Please list the names and contact information of loved ones or friends you would like to recognize.
o Luminaries displaying those names will adorn the Country Club the evening of the Dinner & Dance.
o Please mail this form with your check made payable to American Cancer Society to: Planters Bank, Attn: Leah Keith
P.O. Box 31, Indianola, MS 38751
___________________________________________________________________________________________________________________________
(Purchase of Additional Luminaries)

First Name Last Name Given by (First/Last Name or Family Name)

In MEMORY of ______________________________________ ____________________________________


Address of Family ______________________________________

In MEMORY of ______________________________________ ____________________________________


Address of Family ______________________________________

First Name Last Name Given by (First/Last Name or Family Name)

In HONOR of ______________________________________ ____________________________________


Address of Family ______________________________________

In HONOR of ______________________________________ ____________________________________


Address of Family ______________________________________

_____ TOTAL Tributes Purchased Your Name __________________________________________ Phone # __________________

_____ TOTAL Amount Purchased Address _____________________________________________________________________


($10 each)