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Name: ________________________________________________ Address: ______________________________________________ _______________________________________________ Phone:________________________________________________ Email:_________________________________________________ ______ Tickets - Bar night @ $25 each (includes Picnic) Sorry, No Bar Night Only Tickets ______ Ticket - Picnic $12 per Family Please complete form and make checks payable to: Martin E. Bartnik 2310 William St. Buffalo, NY 14206 Any questions please contact: Mike Ball – mball@buffaloneuro.com – (716) 868-7435 Marty Bartnik - mbartnik@HVSales-USA.com - (716) 818-4588