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YOUR RESERVATION

First name    State
Last name   Zip
Address   Email
City   Phone
Women Attending         
         

PAYMENT INFORMATION: 
$36 cover | $100 sponsor
(Alternatively, you may print this form and mail with a check to Chabad of Larchmont & Mam'k 101 Mamaroneck Avenue • Mamaroneck, NY 10543.)

 I will pay by credit card      I will mail a check     I will pay at the door
Name on card   Amount to be charged
Card Number   Card Type
Exp. Date       CVV Code   3 digits on back of card