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Motorcycle (    )     Auto/Truck (   )     Non-riding Sponsor (   )

Starting Point:____________________ Ending Point:__________________

Name:  __________________________________________________

Corporation:  _____________________________________________

Address:  ________________________________________________

City/State/Zip Code:  ________________________________________

Telephone:  _______________________________________________

eMail:  ___________________________________________________

Corporate Sponsor:      ___ $660

Gold Sponsor:      ___ $66 + $66

Silver Sponsor:      ___ $66

Bronze Sponsor:      ___ $33

Rider Sponsor:      ___ $33

Helper Sponsor: ___ Prayer  ___  Donation of $________

Send all Sponsorships to:

Rodger L. Fox
806 Hardin Ave.
Jacksonville, IL 62650
Phone: 217-473-1525
www.ridefortherelay.com

Make all Checks payable to:  "Relay for Life" Jacksonville