LIMITED SPACE ! RSVP REQUIRED Purim in Africa Party - Reservation Form I'd like to reserve for 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Adults and/ or 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Kids Cover charge: $25 per Adult or Special Price of $80 / Family I would like to sponsor the Purim party for: Patron $180 Partner $360 Other Other Comments: Contact Info: Name: Address: City: Zipcode: Email: Phone: Payment: To pay by check mail to: Chabad of Toluca Lake :10153 1/2 Riverside Drive Suite 567 Toluca Lake, CA 91602 To pay by credit card, complete form below: (otherwise skip to bottom and click submit) Personal Information Same as Above First Name: Last Name: Billing Address: City:State:Zip:Phone no:E-mail: Payment Information Card Type :Please select Amex Visa Mastercard Discovery Name on Card: Card no: CVV Security Code: Expiration Date: Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Total Amount : This page uses 128 bit SSL encryption to keep your data secure.