Brunch Reservation Form Donor Information Title: Dr. Mr. Mrs. Ms. Dr. & Mrs. Mr. & Mrs. Rabbi & Mrs. First Name: Address: Last Name: City: Phone: State: Email: Zip code: Reservation Information I/We are delighted to attend Number of People Mark your selection here 1 x $100 per person = $100 2 x $100 per person = $200 3 x $100 per person = $300 4 x $100 per person = $400 5 x $100 per person = $500 6 x $100 per person = $600 7 x $100 per person = $700 8 x $100 per person = $800 9 x $100 per person = $900 10 x $100 per person = $1,000 Number of Tables Mark your selection here 1 x $1,000 per table = $1,000 2 x $1,000 per table = $2,000 3 x $1,000 per table = $3,000 4 x $1,000 per table = $4,000 5 x $1,000 per table = $5,000 Guest Names I/We are regrettably can not attend I would like to contribute $ Join the Founder's Circle Patron $500 - $1,000 Pillar $1,000 - $5,000 Visionary $5,000 - $50,000 Cornerstone Partner $50,000+ Payment Information Please charge my: Please Choose Visa Mastercard Amex I wish to make a one time payment I wish to pay in # 2 3 4 5 6 8 10 12 monthly installments Card Number: Exp. Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2013 2014 2015 2016 2017 2018 CVV Code: Charge Credit Card Amount: I would like to contribute gift certificate/gift items to Chabad's Silent Auction. Please be in touch with me. Additional Comments/Information: This page uses 128 bit SSL encryption to keep your data secure.
