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* 1. Yes, we wish to participate in the 34th Annual Miracle on Madison Avenue event.  We agree to provide a donation amounting to twenty percent of the in-store sales during the event on December 5 (10am to 5pm) to The Society of Memorial Sloan Kettering Cancer Center.  The maximum donation per participating business is capped at $15,000.  We will abide by all New York State & New York city health and safety rules, including not exceeding 50% occupancy in our store at all times.

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* 2. Contact Name

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* 3. Contact Email Address

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* 4. Boutique Name (as we wish it to appear in all printed materials)

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* 5. Boutique Address

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* 6. Miracle Personal Shopper Name (sales associate assigned to take calls from shoppers wishing to make their Miracle on Madison purchases over the phone)

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* 7. Miracle Personal Shopper Telephone Number

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* 8. Miracle Personal Shopper Email Address

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