Application for PROGRAM Advertisement

1000 Alhambra Drive

Chattanooga, TN  37421

Phone:  423-892-0223

Fax:  423-892-0224

www.alhambrashrine.com

October 6-9, 2011

     Firm Name ___________________________________________________

     Attention ____________________________________________________

     Address _____________________________________________________

     City, ST Zip _______________________   _______   _________________

     Telephone ___________________________ Ad Amount $ _________________

     Approved by:  ___________________________________

                                            Authorized Signature

Thank you for your support of the Alhambra Shrine Circus.  The proceeds are for Alhambra Shrine activities only.  Consult your tax professional as to your specific tax options if any.

     Solicited By  ________________________

     Solicitor's Unit or Club ______________________________

     Date _____________  Check Number __________  Cash ______  Invoice ______

     __________  1/4 Page, $125.00                                       Ad copy instructions:

     __________  1/2 Page, $200.00

     __________  Full Page, $350.00

     __________  Full Page Three Color, $550.00

     __________  Full Page Color, $1,000.00