Bailli Approval: ___________

Name of Restaurant: ___________________________________________

Address: ____________________________________________________

Phone Number: _______________________

Date of Event: ________________________

Chef/Contact: ________________________________________________

Dinner Chair(s): ______________________________________________

Contract Sent: _________

Contract Returned: ________

Restaurant Charge Per Person (All Inclusive): $____________

Wine Budget: $____________ per person

Total Cost: $___________

Admin. Fee: $___________

Member Charge: $___________

Guest Charge: $__________

Music: $___________

Misc.: $___________

Maximum Number of Attendees: _________

Amount Collected

_____Members @ $_____=________

_____Guests @ $_____=________

Non-Paying Guests :$ -_____________

Total Collected: $______________

Monies Outstanding: ______________________

______________________

______________________

______________________

Total $______________

Total Paid Out: $______________

Profit/Loss $______________

Thank You Letter Sent: ____________