GOLFER REGISTRATION FORMI/WE WOULD BE HONORED TO SUPPORT YOUR EFFORTS IN THE FOLLOWING WAYS

Please complete this form and return toJosie Di Chiara

Di Chiara Marketing Group537 Park Avenue

Hoboken, New Jersey 07030or via fax to: 201-710-5021

If you have questions, call Josie directly at 201-208-4540

_____________________________________________________________________________________________________________ NAME AS IT APPEARS ON CARD SIGNATURE

______________________________________________________________________________________________________________ CREDIT CARD NUMBER EXPIRATION DATE

PaymentEnclosed is a check made payable to: Konabona, llc. or please charge:

AMEX MC VISA DISC

First Annual Golf OutingPRESENTED BY PARK & SIXTH COMFORT FOOD

Monday, May 17, 2010 WHITE BEECHES GOLF & COUNTRY CLUB

HAWORTH, NEW JERSEY

Attending the golf tournament on Monday, May 17, 2010 as:

Individual Golfer (including all of day’s events) $250

Foursome (including all of day’s events) $1,000

Name of individual golfer:

1. ______________________________________________________________________________________________

Names of foursome players:

1. ________________________________________________ 2. __________________________________________________

3. _______________________________________________ 4. __________________________________________________

Please provide the following information:

Name:________________________________________________________________________________________

Address:_____________________________________________________________________________________

City: ___________________________________________________ State: ___________________ Zip: ____________

Phone: _______________________________________Email Address: _____________________________________

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