Night of Chocolate Registration September 18, 2015 Doors open at 7 pm Hollywood Casino Columbus 200 Georgesville Road Columbus, OH 43228 Free and valet parking available. Cocktail attire. Night of Chocolate is one of our signature fundraising events and a one-of-a-kind opportunity to support the mission of Cancer Support Community Central Ohio. Please join us for the sweetest event of the year, and help us ensure that no one faces cancer alone! This spectacular evening will recognize the finest chocolate designed to reflect our Willy Wonka-inspired theme. One thousand guests will attend this upscale event and experience chocolate in ways never dreamed possible. Night of Chocolate offers our guests premium, luscious chocolate paired with select wines, premium spirits and outstanding culinary cuisine. Name First Last DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Company Address Address Line 1 Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePhone TypeHomeWorkCellEmail Charlie’s Golden Ticket Sponsor - $1,600 (12 tickets: 10 tickets + 2 tickets for Cancer Support Community Central Ohio cancer survivors)012345678910QuantityGolden Ticket Sponsor - $1,500 (10 tickets)012345678910QuantityIndividual Event Ticket - $175012345678910QuantityPreferred payment method Will pay online at xxxx Please mail an invoice to the address above Enclosed is my check, payable to: Cancer Support Community Central Ohio This Agreement is entered into by and between the Player named above and Cancer Support Community Central Ohio ("CSC") as of 07/28/2021. By signing below, Player agrees to the terms and conditions of this Agreement and the selected participation tier, as described in Charity Golf Classic promotional material. Further, by signing below, Player agrees that Player understands and agrees that this Agreement is the entire agreement between CSC and Player, and may only be revised or amended by a mutually written and executed written amendment. Enter electronic signature Date MM slash DD slash YYYY Checking this box confirms your digital signature If mailing, please submit form and payment to: Attention: Bev Soult, President & CEO Cancer Support Community Central Ohio 1200 Old Henderson Road Columbus, OH 43220 For additional information, please email Rob Alexander, Director of Development and Marketing.