MAGNA CELEBRATIO
Friday, April 30, 2010
*
Please complete all fields.
* Name
* Email
* Address
* City
* State
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Non-US Province
* Zip
* Home Phone
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Admission(s)
at $65 each
$
Online Auction!
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Raffle Ticket(s)
at $100 each ($10,000 prize)
$
I am unable to attend, but wish to contribute.
$
Total
$
Please charge my debit/credit card.
(Visa, Mastercard, American Express, Discover)
* Name
(as it appears on the card)
* Credit Card Type
---
VISA
MasterCard
American Express
Discover
* Account #
–
–
–
* CVN
(
What’s this?)
* Exp. Date
---
1
2
3
4
5
6
7
8
9
10
11
12
/
---
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
* Billing Address
* City
* State
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Non-US Province
* Zip