Print a copy of this this form, one for each seat request, fill it out and send it with your check ( $100 for each seat ) to: Jericho Arts Council Seat Campaign PO Box 62 Bainbridge, NY 13733 Please print clearly. Name: _____________________________________________________ Address: ___________________________________________________ City: ______________________________ State: ______ Zip: _________ Phone: ____________________________ E-Mail: ____________________________ Name for plaque inscription: __________________________________________________________ Make check payable to Jericho Arts Council