Contact Information First Name Last Name Address City / State / Zip Phone Email Ticket Purchase The Jean Fischman Chabad Center of the Five Towns Gala Raffle to be drawn at the Annual Dinner Sunday, December 14, 2014, Kislev 22 at 6:00 PM The Grand Ballroom of the Sands 1395 Beech Street, Atlantic Beach, New York Split the Pot - Be a Winner with Chabad! Split the raffle winnings from “Split the pot” Split the Pot tickets are $10 each How many? 1st Prize: Trip to Israel Two Round Trip Tickets to reconnect with your roots Restrictions Apply Donated by Flywithclass.com How many? 2nd Prize: Decked in Diamonds Two-Toned Diamond Dial Watch: 18K Yellow Gold; 109 Diamonds total WC 0.64ct Valued at $2,345 Donated by The Jeweler’s Wife How many? 3rd Prize: Get Hi-Tech MacBook Air 13 inch: 128GB 1.4G Hz dual-core Intel core i5 processor; Turbo Boost up to 2.7 GHz; intel HD Graphics 5000; 4GB memory; 128GB; PCle-based flash storage Valued at $999 Donated by Mr. & Mrs. Jeremy Kahn How many? 4th Prize: Vacation on the Island Two night’s stay for two lucky people at the New Allegria Hotel, a stunning oceanfront hotel located in Long Beach, NY and a dinner for two at Prime Bistro Valued at $799 Donated by Allegria Hotel and Prime Bistro How many? 5th Prize: Enhance your Shabbat Table Beautiful bouquet of flowers for Shabbat delivered to you every week for one year. (delivery to the 5 Towns & Far Rockaway area only) Donated by Mr. & Mrs. Gidon & Alla Shema of Jerusalem Florist How many? 6th Prize: Vacation in the City A relaxing night out for two at the SOHO Grand Hotel and a Gift Certificate for Dinner at Reserve Cut Valued at $650 Donated by Mr. & Mrs. Jeremy Kahn How many? Tickets: $25 each or 5 for $100. How many tickets are you purchasing in total? Sold by: Payment Card Information If you wish to pay with a check, please fill out this form, print and mail it together with a check to: Checks should be made payable to Chabad of the Five Towns and mailed to 74 Maple Avenue Cedarhurst, NY 11516 Total Amount Credit Card Type Please Select Visa Mastercard Card Number Exp. Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2014 2015 2016 2017 2018 2019 2020 2021 2022 Cvv Code For more information please call: (516) 295-2478