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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 into:

  Prize #1 - How many?    
Parlor Furniture Set, Valued at $6,000
Kindly sponsored by J. Mark Interiors, Inc.
  Prize #2 - How many?    
Two Round Trip Tickets to Israel 
Kindly sponored by Mr. & Mrs. R. Fuchs
  Prize #3 - How many?    
State-of-the-Art Laptop Computer
and a Apple Ipod. Anonymous Sponsor
  Prize #4 - How many?    
1 Night Stay for 2 at a Luxurious New York City Hotel - Includes Dinner for 2 and Limousine Transportation. Anonymous Sponsor

 First Name(s)  
 Address  
 City  
 State  
 Zip  
 Phone  
 E-mail  


SECTION II:  PAYMENT
     
 Charge Amount  

Comments (optional)

 Card Type  
 Card Number  
 Expiration