2016 Tuskegee University Nursing Hall of Fame:
Continuing the Legacy of Dr. Lillian Holland Harvey
TICKET ORDER FORM
CONTACT INFORMATION
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City: _____________________________State: _________________
Phone: (
) _____ - _________ Fax: (
Zip_______________
) _____ - ________ Email: _____________________
Are you a Tuskegee University Graduate? _____Yes _____No If yes, year graduated ______
If yes, please list your discipline (ex. Nursing, Engineering, Social Work, Business, etc.)
_____________________________________________________________________________
Name at the time of graduation if different from the name listed above:
_____________________________________________________________________________
TICKET OPTIONS
(Tickets to attend the GALA are $100 per person)
Number of Tickets
Total Amount for Tickets $________.00
I regret I will be unable to attend, but would like to purchase ______ tickets for a total cost of
$_________.00 to be used by nursing students to attend the gala. If there is a specific student(s) you
would like to use a ticket please specify the name(s) below:
______________________________________________________________________________
If Attending, Please print name (s) of Person (s): (1) ____________________________________
(2)____________________________________
I will make a contribution of $__________.00 to the Tuskegee University Nursing Hall of Fame (Please
note all contributions to the Tuskegee University Nursing Hall of Fame are tax deductible donations)
Make check or money order payable to: Tuskegee University Nursing Hall of Fame
Deadline date for ticket orders: March 4, 2016
Mail to:
Doris S. Holeman, PhD, RN
Associate Dean/Director
School of Nursing and Allied Health
209 Basil O'Connor Hall
Tuskegee University
Tuskegee, AL 36088
Phone: (334) 727-8382
Rev. 10/26/2015