schedule b/w

Name: ___________________________________________________________________________

Address: _________________________________________________________________________

City: State: Zip: ____________________________________________________________________

Contact Person: ___________________________________________________________________

Number of Booth Spaces ____________________________________________________________

Phone Number ____________________________________________________________________

Booth Space	$ 75.00
Inside Booth Space	$150.00
Clean up deposit	$10.00
Electricity	$20.00
Camper Overnight Fee with electricity	$15.00 Per Day - No. of . Days ________
(Sorry no sewage Hook up)
Total Amount Due:	_____________

(Money order or Cashiers check) Payable to Acadia St. Landry Medical Foundation

Will you need electricity? . Yes _______ No _______

What Voltage 110vac _______ 220vac ________

First choice set up Location ___________________________________________________________

Second choice set up location __________________________________________________________

What types of art or crafts will you are selling? _____________________________________________

_________________________________________________________________________________

Please return form to:

Acadia St Landry Medical Foundation

P.O. Box 693

Church Point La.70525-2233