Pink Rose Registration
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1. Registrant Information
Your Name:
Your Name:
*
First
Last
Home Address:
Home Address:
*
Street Address
Address Line 2
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Select a State
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Postal / Zip Code
Country
United States
Phone:
*
Email:
*
Pink Rose Scholarship & Dinner Banquet
Midwest Dream Car Museum - 4/24/26 - 6:00 Start Time
Do you plan to attend the Pink Rose dinner at the car museum?
*
Yes
No
Number of Guests (EXCLUDING YOURSELF) attending the Pink Rose dinner:
*
1
2
3
4
5
More than 5
0
Name of Guest 1
Name of Guest 1
*
First
Last
Name of Guest 2
Name of Guest 2
*
First
Last
Name of Guest 3
Name of Guest 3
*
First
Last
Name of Guest 4
Name of Guest 4
*
First
Last
Name of Guest 5
Name of Guest 5
*
First
Last
IMPORTANT PAYMENT INFORMATION - PLEASE READ!!!
When you submit this form, you will be redirected to PAYPAL to complete your payment. You may use your PAYPAL account, or checkout as a guest. To checkout as a guest, select "Pay with Debit or Credit Card" AT THE BOTTOM. IF you would prefer to pay AT THE EVENT, you may exit the PAYPAL payment screen when it appears. Your submission and opt to pay later will be recorded. IF you are an UNDERGRADUATE, you may also exit the payment screen. Your submission will be also be recorded. THANK YOU FOR YOUR ATTENTION & COOPERATION!
Type the letters you see in the image below.
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