REGISTRATION FORM amfAR Cinema Against AIDS 22 FOR ALL PAYMENT METHODS, PLEASE EMAIL OR FAX to benefit amfAR, The Foundation for AIDS Research THIS FORM TO THURSDAY, MAY 21 ’ 2015 e: CinemaAgainstAIDS@amfar.org Hotel du Cap-Eden-Roc, Cap d’Antibes, France f: +1.917.591.8156 Name (as it should appear on printed materials) Company _! No listing please City State/Country Zip/Postal Code Fax E-mail (required) FOR INFORMATION ON CORPORATE SPONSORSHIP PACKAGES, PLEASE CONTACT ANDREW BOOSE AT a « \/We wish to reserve GRAND PHILANTHROPIST PACKAGE(S) at $275,000 p é, first choice dinner se ating for 12 quests, Co-Chair listing for one ind vidual in event program) ¢ \/We wish to reserve GRAND BENEFACTOR PACKAGE(S) at $200,000 premium dinner seating for 10 quests, Vice Chair listing for one individual in event program) e Wev reserve BENEFACTOR PACKAGE(S) at $150,000 preferred dinner seating for 10 quests, “Benefactor” listing in event program) ° BENEFACTOR “PAIR” at $60,000 B ctor" listing snt program, Vice-Chair listing for one individual in event program) * PATRON TICKET(S) at $20,000 dinner seating, “Patron" listing in event program) e | SUPPORTER TICKET(S) at $15,000 dinne upporter™ listing in event prograrr * |/We cannot attend, but would like to make a contribution to amfAR in the amount of US$ Prices subject to change. If you'd like to reserve, please call to confirm pricing and availability. Grand Benefactor and Benefactor Packages can accommodate up to 12 guests at an additional cost, for more information please contact Christina Christofi. ¢ Acheck made payable to amfAR in the amount of US$ s enclosed * |am transferring funds in the amount c to The Founde S Research (Concentration Account)/ © Please bill my lad AmEx lol visa ‘ol MasterCard ‘J Discover in the amount of US$ C it Card Number Expiration date SEC Signature If corporate card, name of company Checks made payable to amfAR may be mailed to amfAR/Cinema Against AIDS, 120 Wall Street, 13th Floor, New York, NY 10005. For further information, please contact Christina Christofi at CinemaAgainstAlIDS@amfar.org a m fAR or +1.212.806.1611. All tickets are non-refundable. For U.S. residents, $500 of each ticket is a non-tax-deductible charge for food, beverage, and entertainment. Payments in excess of $500 per person and contributions in return for MAKING AIDS HISTORY which no goods or services were received are tax deductible as a charitable contribution (amfAR’s Tax ID 13-3163817). EFTA00296192