Form

Purchase a $10,000 Dinner Dance Ticket

Please complete this form for each ticket purchased.
Full Name *

First Name Last Name

Address *

Phone Number *

- Area Code Phone Number
E-mail *
Amount *

$10,000 Dinner Dance Ticket $ 100.00
You will be directed to Paypal in a few seconds after clicking "Submit", please complete all required information in Paypal or your ticket purchase will not go through.
We are a 501(c)(3) non-profit organization under the regulations of the Internal Revenue Service. All contributions to this organization are tax-deductible to the extent provided by law.
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Purchase a $10,000 Dinner Dance Ticket