RSVP (please Print & mail) 

Steffens Scleroderma Research Foundation

PO Box 38037, Albany, NY  12203

Name                                                                                             

Phone                                  Email                                                 

     Check Enclosed (Payable to Steffens Scleroderma Foundation)

    Please charge my Amex, Discover, MasterCard, Visa

       Card #                                                        Exp date                .

       3-4 digit code (CVC code)                    

Name (as it appears on card)                                                   

Billing Address                                                                             

Authorized Signature                                                                 

Please indicate each guest's entrée choice

_____  Stuffed Chicken Breast          _____  Top Sirloin

_____  Grilled Salmon with Lemon Dill Sauce   _____  Vegetarian Option (available upon request)

___  I would like to reserve _____ number seats at $125/person

____  I would like to be a member of the Honorary Committee at $200/person or _____ $350/couple

___   I would like to reserve _____ table(s) of 8 for $1000 or a table of 10 for $1,250

___   I am unable to attend, but please accept my tax-deductible donation of $                    

                Total amount $                         

Additional Sponsorship levels upon request

For more information, please call (518) 573-0259

click here for online payment

(Please include relevant information such as names, ticket & meal choices in the comment section)