Sold to:

Name: _______________________________

Address: _______________________________

_______________________________

Phone: _______________________________

Cost: 1 Year ($300) _____

2 Years ($500) _____

 

Amount of Contribution: ___________________

Authorized by: _______________________________

Date

Please make check payable to: Brookwood Diamond Club

Mail to:

Brookwood Diamond Club

c/o Melanie Burns

1305 Barnsley Walk

Snellville, GA 30078