USS Horne Reunion Order Form

PRINT THIS FORM OUT AND SEND CHECK MADE PAYABLE TO:
USS HORNE REUNION
AND MAIL TO
FIRST STATE BANK
ATTN: PEGGY BRILLHART
PO BOX 39
WHEATLAND WY 82201

2010 USS HORNE REUNION - RAPID CITY - SD - 08/18/10 - 08/21/10

PACKAGE TYPE	HOW MANY?			PRICE EACH		SUB TOTAL
CUSTER STATE PARK INCLUDES BOX LUNCH (08/19/10) 0900 - 1500		X		$40.00	=	A
CRAZY HORSE MT RUSHMORE (08/20/10 - 1430 - AFTER RUSHMORE LIGHTING CEREMONY)		X		$30.00	=	B
BADLANDS WALL DRUG (08/21/10)		X		$24.00	=	C
ADULT BANQUET (08/21/10)		X		$23.00	=	D
CHILD (AGES 5-10) BANQUET (08/21/10)		X		$12.00	=	E
MAKE CHECK PAYABLE TO: HORNE REUNION NOTE: ORDERS MUST BE RECEIVED BY: 07/10/10			TOTAL ENCLOSED (A+B+C+D+E):

PERSONAL DATA: (PLEASE TYPE OR PRINT)

SHIPMATE NAME:_____________________________________________________

ADDRESS:___________________________________________________________

CITY:______________________________STATE:_________ZIP:_______________

PHONE NUMBER:________________________________________________

EMERGENCY CONTACT NAME & PHONE:________________________________

YEARS ON HORNE: (EXAMPLE: 67-69)___________________________________

NAME DESIRED ON NAME TAG:_________________________________________