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Ticket Request Form

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					     YM-YWHA of
      North Jersey                                                Ticket Request Form
                                                                                             PLEASE PRINT CLEARLY
     973-595-0100 x237
     FAX: 973-995-0061



DATE REQUESTED: ____________________________MEMBER___________ NON-MEMBER___________

NAME: ______________________________________________________________________________

ADDRESS: ___________________________________________________________________________

CITY, STATE, ZIP: _____________________________________________________________________

CONTACT INFO: PHONE ______________________ EMAIL: _____________________________________

                                            Ticket Information
                                 (All inquiries will be addressed within 48 hours.)

____PLEASE MAIL MY TICKETS. ____I WILL PICK UP MY TICKETS.
____I WILL NEED HANDICAP SEATING FOR #_____.

NAME OF SHOW_______________________________________________________________

# CHILD ________ @ $_________ EA. TOTAL $______________
# ADULT ________ @ $_________EA. TOTAL $______________
                                    TOTAL AMT. $______________


                                                  PAYMENT
                                               (PLEASE CHECK ONE)

____CHECK (Please make checks payable to: YM-YWHA OF NORTH JERSEY)
____CREDIT CARD ____CASH

NAME ON CARD: _______________________________________________________________________

ADDRESS OF CARDHOLDER: ______________________________________________________________

____________________________________________________________________________________

CARD TYPE (PLEASE CIRCLE ONE):         VISA       MASTERCARD              AMERICAN EXPRESS        DISCOVER

CREDIT CARD NUMBER: ___________________________________ EXPIRATION DATE: _______________

3 DIGIT AUTHORIZATION # (on back of card) ___________

SIGNATURE_______________________________________________________
_________________________________________________________
                                   FOR REGISTRATION AND BOX OFFICE USE ONLY


DATE: ___________________________ TOTAL PAID $______________________ SOLD BY: _____________________
COMMENTS:

				
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Description: Ticket Request Form