If you will be making a reservation online, you may use the reservation form to submit your ticket purchase

SECTION I:  TICKET PURCHASE

 

 Last Name

 

Prize Packages: $25 each or 5 for $100. How many tickets are you purchasing in total?    

Please select the packages you'd like us to place your tickets in   

    Prize #1 - How many?      
A home interior design package
Valued at $3,500
Donated by J. Mark Interiors, Inc.
                                                         Prize #2 - How many?      
One pair of Judith Ripka earrings-glacier stone drop earring white onyx/white quartz
Valued at $2,100 
Donated by Mr. & Mrs. Jeremy Kahn

   Prize #3 - How many?       
Chest Freezer filled with Amnon’s Pizza & a 1 year membership to Hollywood Atrium valued at $1,500.00 
Donated by Mr. & Mrs. Sol Levy 


  Prize #4 - How many?    
iPad with wi-fi, 16 GB
Valued at $499  
Donated by Mr. & Mrs. Jeremy Kahn   

                                                        
    Prize #5 - How many?      
A free night’s stay for two at the New Allegria Hotel, a stunning oceanfront hotel located in Long Beach, NY, valued at $299. 
Donated by Mr. Allan Rosenberg and family   
 


 First Name  
 Address  
 City  
 State  
 Zip  
 Phone  
 E-mail  


SECTION II:  PAYMENT
     
 Charge Amount  

Comments (optional)

 Card Type  
 Card Number  
 Expiration  
   

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