2018 Lights of Love Registration Form

* Required Fields
I/We Want to Give a Lights of Love Gift
  Amount 




     
Memorial or Honorary Gift Information
  
  This Gift is 
  Honoree
(name as you would like it listed
on the sign and/or program) 
  Given by
(name as you would like it listed 
on the sign and/or program)
 
  Send Acknowledgement To:
(include name and address)
(Optional) 
  SubSolicit Code 


Contact Information
  Title 
* First Name 
* Last Name 
* Address 
* City 
* State 
* Zip 
  Phone 
* Email 
     You will receive a confirmation of this transaction by email.  
                                                     


Credit Card Information
* Card Holder Name 
   
  Card Account Number 
  Expiration Date 
Billing Address -- Please edit if billing address is different.
* Address 
  City 
  State 
* Zip 
                                     



©2018 SofterWare, Inc. v.2018.01.02-C