Political Fundraiser Dinner Registration Web Form

Political Fundraiser Dinner Registration

ONLINE REGISTRATION FORM
July 14-17
6215 N Amsterdam
New York, New York

Item

Description/Amount

Quantity

Total

Primary Registration:

Recommended Donation per Plate

Guest Registration:

Recommended Donation per Plate

Additional Donation

Grand Total:

Personal Information

*E-Mail:

Valid e-mail is required

*First Name:

*Last Name:

*Address Line 1:

Address Line 2:

*City:

*State:

*Zip Code:

*Phone:

Credit/Debit Card Information

*Card Number:

No dashes or spaces please

*Expiration Month:

From your card

*Expiration Year:

From your card

*Card Brand:

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