PATRON REGISTRATION

Patron Name: __________________________________________________________

Patron Address: ____________________________________________________

____________________________________________________

Patron Phone: ___________________ Patron Fax: _______________________

Patron Email: __________________________________________________________

Patron Contact Person: ______________________________________________

ITEM	PRICE	AMOUNT ENCLOSED
2004-2005 FSSL Patron Membership NOTE: Please enclose your business card size ad as you would like it to appear in our newsletter.	$50.00
2004 FSSL Flute Day Booth Registration	$25.00
2004 FSSL Flute Day Program Ad Front Inside or Back Inside or Outside Cover (first come, first served) Half (1/2) Page Ad One-fourth (1/4) Page Ad Business Card Size Ad NOTE: Please enclose your ad along with this registration form.	$150.00 $100.00 $50.00 $25.00
Co-Sponsor for Mimi Stillman Concert	$300.00
TOTAL AMOUNT ENCLOSED

PLEASE RETURN FORM TO THE FOLLOWING ADDRESS BY OCTOBER 15, 2004: Colleen M. Donohue

Michael E. Maglari, P.C.

16640 Chesterfield Grove Road, Suite 110

Chesterfield, MO 63005

Please make checks payable to: Flute Society of St. Louis