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Political Fundraiser Dinner Registration
ONLINE REGISTRATION FORM
July 14-17
6215 N Amsterdam
New York, New York
ItemDescription/AmountQuantityTotal
Primary Registration:
  Recommended Donation per Plate
Guest Registration:
  Recommended Donation per Plate
Additional Donation   
Grand Total:
Personal Information
*E-Mail:Valid e-mail is required
*First Name:
*Last Name:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
*Phone:
Credit/Debit Card Information
*Card Number:No dashes or spaces please
*Expiration Month:From your card
*Expiration Year:From your card
*Card Brand:
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