EmailMe Form - Coffee Break® 2019 Retailer Registration Form

Name *

First Last

Organization/Company Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

### - ### - #### Ext. ###

If no extension, please enter 000 into the box above.

Fax

### - ### - ####

Email

Start of Coffee Break® event

DD / MM / YYYY

End of Coffee Break® event

DD / MM / YYYY

*

The above is a firm date.

The above is a tentative date.

Our organization wants to participate but doesn't have a date yet.

Note: To be eligible for the champion title and other awards, please return donations by November 4, 2019.

How many cut-outs do you expect to sell? *

Less than 250

250-500

500-1000

More than 1000

A Coffee Break Kit contains forget-me-not cut-outs, balloons, posters and other promotional materials

Items to include in your host kit:

Donation Box

Plastic Banner

Brochures

Balloons

Store Matching

Our organization will support Coffee Break® by matching sales of the paper cut-outs.

I want to do more, please contact me about:

Other ways to help

Other events (ie. Walk for Memories, Tag Days)

Contact Information:

Barrie Office
20 Anne St. S. Unit 3 P.O Box 1414
Barrie, ON L4M 5R4
Telephone: 705-722-1066
Toll Free: 1-800-265-5391
E-mail: funddev@alzheimersociety.ca