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<br />MAY 20 2005 12:32 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br />02/08/02 PRI 10:32 PAX TJ ADAKS GROUP <br />TJ ~AM~.~~9!g~ <br /> <br />P.03/03 <br /> <br />IirI002 <br /> <br />R6QUEST FOR MONS CERTIFICA TES OF INSURANCE <br />.....NOTE: WE REQUIRE 7 BUll_ft." DAVS TO PROCell THIS REQUEST...... <br /> <br />Dete '7 -;Z-e> -t:;C7 <br /> <br />Thl. form cln either b. faxed or man.d to T. J. Adam. Group, LLC <br /> <br />" <br /> <br />Addre..: 333 E. Butterfield Rd., ate. 500 <br />Lomb.rd,'IL 80148 <br />"ttn: Marcl Ray.. <br /> <br />CLUB INFORMATION: <br /> <br />Fad: (130)3Uo2761 <br />Attn: Marol Rey.. <br /> <br />Name of Llonl Olub <br /> <br />?-rIa-I-re-i2-V11_l.--t:f"'" L--l~> ~,l3- <br /> <br />Addre.. -;1l?'7 6j;l..IA...l ~I\/", <br />City. SlIIte. Zip ./ ,",~i2-\fn_\.-U . ",,_I c.:;';;b>B <br />. <br /> <br />EVENT INFORMATION: <br /> <br />~ - 'I - d II <br />Elvent ~bt:>':? l-I:l~~ ~:!> L-A~~ <br /> <br />le(l) of Event <br /> <br />Au J-.\-,~ <br /> <br />4-. c:; . b. 7 ?-, .. '7-rH ?-cP7 <br />. . , <br /> <br />Loeallon of Event <br /> <br />L_"'wi:2-\~ <br /> <br />r__A'M~.c +='A-i2.-\L. /_c-_/"I~;2.J,~ <br />, <br /> <br />- <br /> <br />CERTIFICATE HOLDER/ADDITIONAL INSURED INFORMATION: <br /> <br />Certificate Holder: <br />(party requiring <br />certiflcate from <br />your club) <br /> <br />.?-\:t or L4~<7i:2-\tlL..-L~ <br />\ ~ SS"/:;) lM AI.. I ~F"12"-- <br />./ l!e"rTi...P-V\~ ,M-' '7'703>9., <br /> <br />Addlllonlllnlurada: (In ord.r 10 be .n eddltJonalln.Urld, the PlIrty must own the prem.... on which you <br />are conducting X!ur evenl ~ a PUDllc blllly l..uln; I peE!!!ll): <br />U None J.4 Ssm. II Certlftcele Hold.r U Different from C.rt. Holder <br /> <br />MAILING/FAX INFORMATION: <br /> <br />,/ <br />Send To (rf maillnlil): <br />OR <br /> <br />RequlIlItedBy: h;2Eb. ILI€~H=~ <br />Phon. . whe,. you 08n b. r..ch.d for quertlon.: bl2- - 'Z-Z-l _ <}I~~ <br /> <br />CJ Fax Numb.r: <br /> <br />.... PIe... f..1 '....10 Ittach I copy of I..t y..,. certlflclt. If IVllllbl. with In)' n.c....IY oh.n"....... <br />** TOTAL PAGE.03 ** <br /> <br />~;Zcsc. j.t...\~~H-t>~- <br />9 '6i2-. ~ ~v- <br />~~l~ r ~ ~S'P3-€. <br />