Trivia Night

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

1 - Select registration type below*

Total people/families you are registering

Total due MEMBERS

2ND REGISTRATION - Select registration type

Total people/families you are registering

2Total due MEMBERS

3RD REGISTRATION - Select registration type

Total people/families you are registering

3Total due MEMBERS

4TH REGISTRATION - Select registration type

Total people/families you are registering

4Total due MEMBERS

TOTAL AMONT DUE

Select Payment type*

CheckCredit Card

Please consider paying an additional $3.00 to cover the bank fees incurred when using a credit card

Yes, I will be happy to pay an additional $3.00 to cover the bank fees.No thank you, charge my credit card the original amount.

Total being changed you your credit card.

If you wish to pay your ${totalAmont} registration fee by check, please mail your check by November 10th, to the temple at the address below. Please write "Jewish Trivia Night" in the check memo area.

Temple Beth El

5150 Peridia Blvd. East

Bradenton, FL 3420

Amount being charged to Credit Card

USDJewish Trivia Night (fundraiser)

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Date