Registration Form

*Send to: Seeds of Hope, c/o Sam Malone, 5440 Wilderness View St, Lincoln, NE 68512.

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Name:                                                                                                                   

 

Street Address:                                                                                                    

 

City:                                                              State:          Zip:                             

 

Email Address:                                                                                                      

Vehicle Information

 

Year:             Make:                    Model:                                      Color:                 

 

Year:             Make:                    Model:                                      Color:                 

*additional vehicles attach to this form

 

Vehicle(s)     # ______ @ $15.00 each          =        $____________

 

Luminary(ies) # ______@ $10.00 each         =        $____________

 

Grand Total:                                                          $_________________

*Make checks payable to “American Cancer Society”

Luminary Message:

Tribute Type (Select one)

           In Memory of

           In Honor of

           In Support of