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<br />JAN 25 2004 13:13 FR ARTESYN ENGINEERING 5123925740 TO 95514298529 <br />02/08/02 tal 10:32 FAX TJ ADAIl! GROUP <br /> <br />.. TJ r@hM~II~~9M~ <br /> <br />P.08/11 <br /> <br />ilIIOOX <br /> <br />Addre..: 333 E. ButWrfield Rd., Ste. aoo <br />L~mblrd,.IL 10148 <br />Attn: Marcl R'y" <br /> <br />CLUB INFORMATION: <br /> <br />Fad: (130)3M-2781 <br />Attn: Marcl Ray.. <br /> <br />Nama Of LIO"I Club <br /> <br />LlZl-J"I"a:.?;2.VIl.-<-~ L-tClr->> ~i) <br /> <br />Addrlllll <br /> <br />"'71 r,; q ~A....I ~\;;.: <br /> <br />city, Slate, Zip <br /> <br />/' ~.sT'a~~L.r-J'" <br /> <br />IAA__ <br />, <br /> <br />q-CjD>"7S <br /> <br />EVENT INFORMATION: <br />Event ~c>4'\ t==L~~ r;:::.f~ L-A.L$ -/ L:.-rr-l RE'!ff"\\JAL- <br /> <br />tll) of Event <br /> <br />AtJ.!>-\J~l ~ I ... ~ ~D+ <br />, . <br /> <br />Location of Event ~A"'~ ~~, ~6.Jni2-V,~ ""'""";> pet... 'T1e-;;2 L-A-I"-e-> <br />CERTIFICA Ta HOLDER/ADDITIONAL INSURED INFORMATION: <br /> <br />?--1-r1 Di~ /...L';~iZ'\Il~ <br />_I~go r"A.. 4~","1- <br />""'- ~-e2J.I.........sF ",.....I CiC;D"3B <br />, <br />hC?1 - .4-2.9 - "3>"k 302- <br /> <br />Addllfonal'nllurad,: (In ord.r to ba an addition, I in.ur.d, the partY mUlt own thl ptem'", on which ~ou <br />Ire conducting ~ur ..,.nt 'it,1l..J a PUblic ba4~ .aul"g . PI!:!!!lt): <br />U NoneI,.2KSame sa CtrtlfiC8'- Holder W Different from Cert. Holder <br /> <br />Cartltleele Holder; <br />(party reqlollrlnSl <br />ce~t. from <br />your club) <br /> <br />MAILlNQ/FAX INFORMATION: <br /> <br />Requlltld B~: ;L i7 &;i- 1L-16>Ei~j2$j'"'" <br />Phone" whl" you clIn bo rNch..:! for qUlJ!ltlona: 1",12-- 2.2 \ -<:J 12-2. <br /> <br />~b. ILII?~~"S> r <br />~? BiZ-V<:..> L::::e-IV€ . <br />e~\Jt'-""'~, "",,-, 5'703ts <br />_FllXNlimb.r: b'?I-~9-BbZ.7' ~'.~I2e".6A i3e:....~~ <br /> <br />.... Pleau fI.1 fr.. 10 attacll a copy of ,..t yeart Glrt,ncltelf ..,III.bl. with any n,e,,,ary chang....... <br /> <br />~S8nCl To (If maillnSl): <br />OR <br />