89th Anniversary Commemoration

TICKETS FOR PROGRAM FEATURING AUTHOR JAY BONANSINGA


(Note: The "dues-paying member" ticket prices apply to you and your immediate family only, where immediate family includes you, your spouse, and your children.)
NAME (please print) DUES-PAYING
MEMBER?
TICKET PRICE
 
ORDER SUBTOTAL
MEMBERSHIP** (optional)
ORDER TOTAL


PAYMENT INFORMATION
Personal check Cashiers check Money order
VISA MasterCard

CREDIT CARD INFORMATION
(if paying by VISA or MasterCard)
Account number
Expiration date
 
Card authorization number
(last 3 or 4 digits on reverse side of card)
Name (as it appears on credit card)
Address

City
State
Country
Postal code


MAILING INFORMATION
(Please provide only if different from credit card information.)
Name
Address

City
State
Country
Postal code


CONTACT INFORMATION
(person we will contact if there is a problem with the order)
Phone number
Email address


**Please complete a membership application and include this with your order.

Your privacy is important to us and for this reason we do not accept credit card information electronically via this form or via email.  With the confidentiality of your personal information being of the utmost importance, we ask that you type or print the information on this form and mail or fax it to us.  Or you may call us with this information and we will gladly process your order over the telephone.