2013 CCA Northern Virginia Chapter – Dinner Auction Registration Form- Mail to Carl Onesty, CCA NoVA Treasurer, 8529 Pappas Way, Annandale VA 22003
Name: _________________________________________________________________ Telephone: ________________________
Address: _______________________________________________________________
City/State/Zip: _________________________________
E-Mail:______________________________________________________ □ Please E-Mail me with confirmation of registration.
□ Single Ticket (includes new Membership or Renewal)…………… $50 I am a: □ new member □ renewal
□ Two Tickets (includes two New Memberships or Renewals)………………… $100
□ Blue Marlin Table: 8 people, (includes 8 Membership or Renewals)..…… $500 Table Name:________________________
Includes a $100 Live Auction Coupon good toward an Auction Purchase (this name will appear on your table sign)
□ My Check is enclosed in the amount of $ _____________ Payable to CCA N. Virginia
□ Please Charge to my VISA / Master Card. Account Number:___________________________
Expiration Date:_______________ Signature:_________________________________________
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