Form

Alpha Phi Alpha 3inOne Ticket Sales 2012

Lee B. Revels Mentoring & Scholarship Foundation
First Name*
Last Name*
E-mail*
Phone Contact Number*
Street Address*
City*
State*
Zip-Code*
Alpha Brother You Are Supporting*
Select Brother you are supporting
Method of Payments*
Select Number of Tickets
Ticket Delivery Options*
Select your option
Confirm Contribution
One Ticket $40.00 USD
Two Tickets $80.00 USD
Three Tickets $120.00 USD
Four Tickets $160.00 USD
Five Tickets $200.00 USD
Six Tickets $240.00 USD
Secure Payment Memo
After you submit this request you will be redirected to our secure bank
proccessing partner. We will not have access to any of your credit card
information. This is handled by Pay Pal and you may pay by Credit Card.
Please Make Your Check Payable To:
Lee B. Revels Scholarship Fund

Mail Check:
Lee B. Revels Scholarship Fund
TILChapter
PO Box 4233
Springfield, MA 01101-4233
Date To Expect Check
Comments
Security Verification*
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Alpha Phi Alpha 3inOne Ticket Sales 2012