Purim at the Shore Reservations Thursday, March 5, 2015 · 5:30 pm Regency House-Best Western Hotel 140 Route 23 • Pompton Plains, NJ First Name: Last Name: Address: City: State: Zip: Phone #: Email Number of people attending: # of Adults and children 14 and older $28 per Person # of Children: 3-13 years $10 Children under 3 free I want to make a contribution to help sponsor the Purim Fest! ( your Name will be announced at the event) of: $3600.00 $1800.00 $1000.00 $500.00 $180.00 $100.00 Other $ US Payment information I will pay with a credit card check/cash Billing Information Credit Card Type MasterCard Visa American Express Discover Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 2015 2016 2017 2018 2019 2020 2021 Security Code Signature of name on card Total $ *Please mail check to the Chabad Center 194 Ratzer Road Wayne NJ 07470 in time for it to arrive at least 3 days before the event. This page uses 128 bit SSL encryption to keep your data secure.