Patron Information: * FirstName * LastName * Address * City * State * zip * Home/Cell Phone Office Phone * Email Donation Number of Tickets ($50 each) 0 ($ 0) 1 ($ 50) 2 ($ 100) 3 ($ 150) 4 ($ 200) 5 ($ 250) 6 ($ 300) 7 ($ 350) 8 ($ 400) 9 ($ 450) 10 ($ 500) 11 ($ 550) 12 ($ 600) 13 ($ 650) 14 ($ 700) 15 ($ 750) 16 ($ 800) 17 ($ 850) 18 ($ 900) 19 ($ 950) 20 ($ 1000) 21 ($ 1050) 22 ($ 1100) 23 ($ 1150) 24 ($ 1200) 25 ($ 1250) 26 ($ 1300) 27 ($ 1350) 28 ($ 1400) 29 ($ 1450) 30 ($ 1500) 31 ($ 1550) 32 ($ 1600) 33 ($ 1650) 34 ($ 1700) 35 ($ 1750) 36 ($ 1800) 37 ($ 1850) 38 ($ 1900) 39 ($ 1950) 40 ($ 2000) 41 ($ 2050) 42 ($ 2100) 43 ($ 2150) 44 ($ 2200) 45 ($ 2250) 46 ($ 2300) 47 ($ 2350) 48 ($ 2400) 49 ($ 2450) 50 ($ 2500) Pick up at the Banquet: Would you like to Add donation? Amount of Donation: $ (This is other than ticket cost) Add Souvenir book ad payment? Payment towards Ad. in souvenir book: $ Do you have Children who is participating in Cultural Program ($25/child)? 0 ($ 0) 1 ($ 25) 2 ($ 50) 3 ($ 75) 4 ($ 100) Do you have Children 5 to 10 years old that you would like to provide Babysitting at Banquet $20/child)? 0 ($ 0) 1 ($ 20) 2 ($ 40) 3 ($ 60) 4 ($ 80) 5 ($ 100) 6 ($ 120) 7 ($ 140) 8 ($ 160) 9 ($ 180) 10 ($ 200) Comments (If you know the Table #, please enter the Table #) Please choose a payment method: Paying by Zelle to accounts@mychinmaya.org Paying by Check Paying by Cash Paying by CC (For paying by CC option, you will be taken to the credit card payment page via paypal.) Instant SSL Certificate Secured

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