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*Journal ads of $500 and above include dinner reservations for two.
Please make reservations at $180.00 per person.

General Donation

Order Total: $  
Personal Information
First Name: *
Last Name: *
Company Name:
Address: *
City: *
State: *
Zip Code: *
Country: *
Phone Number: *
Cell Phone:
Email Address: *
Payment Details
Card Type: *
Card Number: *
Exp. Month: *
Exp. Year: *
Security Code: *
Additional Information
Solicited By:
Ad Text:
Seating Preferences / Additional Comments:
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(in addition to the receipt I will receive via email).
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Tashbar of Lakewood is a non-profit 501c3 organization.