Name  
Address     City     State     ZIP  
eMail Address     Phone  
Reservations will not be considered complete without full payment.
Name
Use a separate line for each person
Membership
Number
Number
of Tickets
Cost
$65 member
$70 other
A. Chicken Entrée
B. Salmon Entrée
C. Vegetarian Entrée
 1.       A.  B.  C.
 2.       A.  B.  C.
 3.       A.  B.  C.
 4.       A.  B.  C.
 5.       A.  B.  C.
 6.       A.  B.  C.
 7.       A.  B.  C.
 8.       A.  B.  C.
 9.       A.  B.  C.
 10.       A.  B.  C.
Please check if you would like to be
     seated at a singles table.
Total  
$ for singles, couples
or groups
dance hosts available
 
Reservations only – no tickets sold at the door.

Please make checks payable to
USA Dance, Chicagoland Chapter #2001
Send to Susie Johnson, President
10 Wildwood Drive North
Prospect Heights, IL 60070-1043
for more information call 847-274-6312