PRE-SALE PAYROLL DEDUCTION FORM LMG HOLIDAY POD FAIR

DECEMBER 3RD, 2019 Today’s Date: _____________________________ Pod/Practice Name: ___________________________ Employee Name:_____________________________________ Payment Method: Payroll Deduction (deducted

from Dec. 13th, 2019 check)

Ticket Pricing if you buy before November 22nd: (check only one box) 5 for $25 35 for $150 15 for $50 40 for $175 ______ for $______ 20 for $75 45 for $200 25 for $100 50 for $225 30 for $125 55 for $250

Total Amount Purchased: $ ____________________

Employee Signature: _________________________ Office Manager Signature: _________________________ If you are unable to attend the event, please list the name of the person picking up your tickets: ___________________________________________

*NON-REFUNDABLE. PICK UP TICKETS AT THE WILL CALL TABLE ON DEC. 3RD*

*THIS FORM IS DUE BACK VIA EMAIL TO [email protected] NO LATER THAN NOVEMBER 21ST*