HAITI Cagy/ilea ein/ C6ap //05 A Gala For Haitian Relief Benefiting J/P Haitian Relief Organization, Artists for Peace and Justice, Happy Hearts Fund The Agora Pavilion at the Cannes International Film Festival Friday, May 18, 2012 - 9:30PM - TICKET/TABLE REGISTRATION FORM - Name (as it should appear on any printed materials) Company No listing please El Address City State/Country Zip/Postal Code Tel Fax Email I/We wish to reserve $100,000 MARDI GRAS - TABLE FOR 12 • 5 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh • Premiere placement in the room l/We wish to reserve $75,000 BAND MASKE - TABLE FOR 10 • 2 tickets to the After Party hosted by Paul G. Allen on board M/Y Tatoosh l/We wish to reserve $50,000 BAND A PIED - TABLE FOR 10 All table purchases will receive acknowledgement in the program as a category respective supporter. For inclusion in the program, tables must be purchased by May 8, 2012. l/We wish to reserve $7,500 BAND MASKE TICKET l/We wish to reserve $5,000 BAND A PIED TICKET I/We cannot attend, but would like to make a contribution in the amount of $ Please bill my: El Visa AmEx El MasterCard ID Diners Club in the amount of US$ Credit Card Number Exp: Security Code: Signature If Corporate Card, Name of Company Bank Transfer: I am transferring funds in the amount of US$ to City National Bank ABA # 1220-1606-6 for credit to J/P Haitian Relief Organization -Account 0123-572394 (Swift Code: CINAUS6LI Checks. made payable to J/P HRO, may be mailed to 6022 Wilshire Blvd, Suite 203, Los Angeles, CA 90036. For further information, please call the RSVP Information line at 1310) 9283880 or email HaitiRSVP63veventpro.com. All tickets are non-refundable. For U.S. residents. $350.00 of each ticket is a non-tax-deductible charge for food, beverage, and entertainment. Payments in excess of $350.00 per person and contributions in return for which no goods or services were received are t