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Make checks payable to the American Cancer Society.
Return this form and your donation to a Team Captain or to
P.O. Box 165, Roxboro 27573
(Only
one name per luminary.)
Honoree’s
name as it should appear on the luminary bag:
_______________________________________________________________________
Your
name as it should appear on the luminary bag:
________________________________________________________________________
Please
use a new sheet for additional luminaries.
Your
Phone (required): ___________________________________________________
TEAM
Name (if
applicable): _______________________________________________
Amount enclosed: $____________