2023 Blue Gala Payment Form

CITY OF HOPEWELL HEALTHY FAMILIES
2023 BLUE GALA PAYMENT FORM

ATTENDEE INFORMATION:

Payment Date:

06/10/23

* Attendee Name(s):

Enter the first and last names of attendees separated by a comma.

TICKET INFORMATION:

$51.50 (Includes 2.95% processing fee):

Enter the number of tickets you wish to purchase.

$500.00 Corporate Table Sponsorship:

Enter the number of corporate tables you wish to sponsor.

Total Charge:

CREDIT CARD INFORMATION:

*Card Type:

*Card Number:

*Card Expiration Date:

MMYY

*Card ID (CVV2/CID) Number:
[ What is the Card ID ?]

*Name on Card:

*Card Billing Address:

*Card Billing Zipcode:

*Email Address:

Contact Us

Hopewell-Prince George Healthy Families
300 N. Main Street
Hopewell, VA 23860
Phone: 804-352-4018 ext. 645