Gala Tickets Thursday, September 19th, 2024 at 6:00 pmThe Suburban Club This field is hidden when viewing the formDateThis field is hidden when viewing the formCustomer NumberName(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Choose the type of sponsor you are...(Required)Choose a TypeCompanyIndividualInkindCompany NameChoose a Sponsorship Level Gold Table ($5,000) Silver Table ($3,000) Ticket Only ($300) Gold Table and Silver Table Sponsorships receive an ad in the Ad Book.This field is hidden when viewing the formSponsorship Type for FilemakerWould you like to purchase additional tickets?(Required) Yes No Additional Tickets Quantity(Required) Price: $300.00 Quantity Additional Tickets Subtotal $0.00 Ad BookIf you are not purchasing a Gold Table or Silver Table Sponsorship you are welcome to purchase an ad in the Ad Book.Select Ad Book SizeInside Front Cover ($1,000)Inside Back Cover ($1,000)Back Cover ($1,000)Full Page ($500)Half Page ($250)This field is hidden when viewing the formOther ContributionThis field is hidden when viewing the formStraight DonationThis field is hidden when viewing the formAdditional Tickets to FilemakerHow would you like to pay?(Required) Credit Card Check This field is hidden when viewing the formPaid or PledgeThis field is hidden when viewing the formPayment MethodMake Checks Payable to: Dyslexia Tutoring Program The Rotunda, Suite 310, 711 W 40th Street, Baltimore, MD 21211Would you like to cover the fee we pay to process credit cards? Yes, add the credit card fee to my purchase Subtotal $0.00 Credit Card Fee Price: $0.00 Total Payment MethodCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Please Note: After clicking submit please wait a few seconds for processing.Once your payment is processed you will receive a notification. 15358
