Payment Information
Yes! I would like a chance to win $10,000.00 while supporting the Mesivta Scholarship Fund!
Amount
$540 - 45 Tickets
$360 - 25 Tickets
$180 - 10 Tickets
$100 - 5 Tickets
$36 - 1 Ticket
Other amount
*
Please charge amount above to this card every month for 12 months.
Contact Information
Title
Title
Mr.
Mrs.
Ms.
Dr.
Mr. & Mrs.
Dr. & Mrs.
Rabbi
Rabbi & Mrs.
First
*
Last
*
Phone
Email
*
Address
City
State
Zip Code
Credit Card Information
Use contact info above
Name on Card
*
Card Type
Card Type
Visa
MC
Amex
Discover
*
Number
*
Expiration
Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
*
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
*
Code
*
Zip
*
Other Information
Comments
Honor
Memory
Purpose
Purpose
Raffle
Other
Other
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