PLEASE USE THIS FORM TO PURCHASE TICKETS. Thank you for your generous contribution supporting our Fellowship Program for emerging artists and writers.   First Name   Last Name   email   Address   City   State Zip Telephone   $150 Ticket: Quantity     $500 PATRON: 2 Tickets • Listing in evening program Quantity     $1,000 BENEFACTOR: 2 Tickets & 2 Post-Reception Dinner Tickets to TROY Boston • Listing in evening program Quantity     $2,500 GOLD BENEFACTOR: 4 Tickets & 4 Post-Reception Dinners Tickets to TROY Boston • Listing in evening program Quantity     I am unable to attend but I would like to make a contribution of $   I am a current FAWC member at the $250 Supporting Level or above. Please apply 10% discount. TOTAL   $  visa mastercard discover American Express Cardholder name: Card # Exp.date    Card Verification Number*  *For your safety and security, we require that you enter your card's verification number. This is 3 or 4 digit number printed on the back of your card. Comments: (also, please list your name as you would like it to appear in the evening program and the name(s) of your guests.)   Thank you for joining us at this upcoming event.