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LIMITED SPACE ! RSVP REQUIRED

Purim in Africa Party - Reservation Form

I'd like to reserve for  Adults and/ or  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 

Name on Card:

Card no:

CVV Security Code:

Expiration Date: Month  Year 

Total Amount :