Print & Mail Form Below to:
                                 Berean Bible Church
                                  109 County Rd. 2
                                                  Greene, NY 13778

                                           Ticket Order form For
                                           Give Me Five Concert
                                          August 23rd  ^- 12:00 pm

 Name _________________________________________________________

 Address________________________________________________________

 ______________________________________________________________

 Phone Number__________________________________________________

 Email address___________________________________________________

 Number of tickets requested _______ x $40.00 each =  _______
              (children 12 and under - free admittance with adult)

 ($1.00 Extra per ticket if using a credit card)           ________

 Total  purchase                                                            ________

 Checks payable to THE IMPACT PROJECT

 Credit/Debit Card      Visa           Master Card    ( Circle one )

 Card Number __________________________________________________

 Expiration Date                       /                /

 Security Number  __________________________

   ( Visa has 3 digits/ Mastercard has 4 Digits )