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<p align="center"><span style="font-size: 14px"><strong>Purim at the Circus</strong></span></p>

<p align="center">Wednesday, March&nbsp;7th &middot; 6:00pm</p>

<p align="center">&nbsp;<span style="font-size: 14px">$18 PER&nbsp;ADULT $12 PER CHILD (under 2 free) (Family Max $72)</span></p>

<p align="center"><span style="color: #ff0000">If you&nbsp;are RSVP'ing before March 1st $15 Adult and $10 Child</span></p>

<p align="center">&nbsp;<span style="font-size: 14px">Evening&nbsp;Sponsorship $180 Patron $360</span></p>

<p align="center"><input tabindex="1" size="5" required="true" style="width: 43px; height: 22px" name="Number of adults" type="text" />&nbsp;Number of Adults&nbsp; <br />

<input tabindex="2" size="5" required="false" style="width: 43px; height: 22px" name="Number of children" type="text" />&nbsp;Number of Children</p>

<p align="center"><input tabindex="3" size="5" required="true" name="x_amount" value="$" type="text" />&nbsp;Amount to Charge to CC or&nbsp;being Mailed in&nbsp;</p>

<table class="covertype" border="0" cellspacing="0" cellpadding="6" width="439">

    <tbody>

        <tr>

            <td height="6" valign="top" width="121">First Name<span style="color: #000000">*</span></td>

            <td height="6" valign="top" width="290"><input class="light" tabindex="4" required="true" style="background-color: #ffffa0" name="x_first_name" type="text" /></td>

        </tr>

        <tr>

            <td height="6" valign="top" width="121">Last Name<span style="color: #000000">*</span></td>

            <td height="6" valign="top" width="290"><input class="light" tabindex="5" required="true" style="background-color: #ffffa0" name="x_last_name" type="text" /></td>

        </tr>

        <tr>

            <td height="47" valign="middle" width="121">Address Line 1<span style="color: #000000">*</span></td>

            <td height="47" valign="middle" width="290"><input class="light" tabindex="6" required="true" style="background-color: #ffffa0" name="x_address" type="text" /></td>

        </tr>

        <tr>

            <td height="21" valign="middle" width="121">Address Line 2</td>

            <td height="21" valign="middle" width="290"><input class="light" style="background-color: #ffffa0" name="Address2" type="text" /></td>

        </tr>

        <tr>

            <td height="12" valign="middle" width="121">City*</td>

            <td height="12" valign="middle" width="290"><input class="light" tabindex="7" required="true" style="background-color: #ffffa0" name="City" type="text" /></td>

        </tr>

        <tr>

            <td height="13" valign="middle" width="121">State</td>

            <td height="13" valign="middle" width="290"><input class="light" tabindex="8" size="10" required="true" style="background-color: #ffffa0" name="x_state" type="text" /></td>

        </tr>

        <tr>

            <td height="12" valign="middle" width="121">Post Code<span style="color: #000000">*</span></td>

            <td height="12" valign="middle" width="290"><input class="light" tabindex="9" size="10" required="true" style="background-color: #ffffa0" name="x_zip" type="text" /></td>

        </tr>

        <tr>

            <td height="13" valign="middle" width="121">Country</td>

            <td height="13" valign="middle" width="290"><input class="light" tabindex="10" required="false" style="background-color: #ffffa0" name="x_country" type="text" /> <!--<SELECT class=light

      name=Country>

      <OPTION value=" "

      selected>

      <OPTION>Mr.</OPTION>

      <OPTION>Mrs.</OPTION>

      <OPTION>Mr. &amp; Mrs.</OPTION>

      <OPTION>Dr.</OPTION>

      <OPTION>Dr. and Mrs.</OPTION>

      </SELECT>--></td>

        </tr>

        <tr>

            <td height="13" valign="middle" width="121">Phone</td>

            <td height="13" valign="middle" width="290"><input class="light" tabindex="11" required="false" style="background-color: #ffffa0" name="x_Phone" type="text" /></td>

        </tr>

        <tr>

            <td height="21" valign="top" width="425" colspan="2">Email Address* <input tabindex="12" size="25" required="true" style="width: 200px; height: 22px" name="x_email" type="text" /></td>

        </tr>

    </tbody>

</table>

<p><input tabindex="1" type="radio" name="Radio" value="charge me" />Please charge my Credit Card</p>

<table class="covertype" border="0" cellspacing="0" cellpadding="6" width="441">

    <tbody>

        <tr>

            <td height="21" valign="top" width="122">Card Type</td>

            <td height="21" valign="top" width="291"><select class="light" tabindex="1" name="CCType">

            <option value="Visa" selected="selected">Visa</option>

            <option value="Master Card">Master Card</option>

            <option value="American Express">American Express</option>

            <option value="Discover">Discover</option>

            </select></td>

        </tr>

        <tr>

            <td height="21" valign="top" width="122">

            <p>Card Number</p>

            <p>Security Code</p>

            </td>

            <td height="21" valign="top" width="291"><input class="light" tabindex="13" required="false" style="background-color: #ffffa0" name="x_card_num" type="text" />&nbsp;<input class="light" tabindex="14" required="false" style="background-color: #ffffa0" name="x_card_code" type="text" /></td>

        </tr>

        <tr>

            <td height="21" valign="top" width="122">

            <p>Expiration Date mm YYYY</p>

            </td>

            <td height="21" valign="top" width="291">

            <p>&nbsp;<input tabindex="15" size="8" required="false" style="width: 68px; height: 22px" name="x_exp_month" value="MM" type="text" />&nbsp;<input tabindex="16" size="6" required="false" style="width: 60px; height: 22px" name="x_exp_year" value="YYYY" type="text" /></p>

            </td>

        </tr>

    </tbody>

</table>

<p>&nbsp;</p>

<p>Please check here to be a family sponsor @ $180 <br />

<input tabindex="1" type="radio" name="Family Sponsor 180" value="Family Sponsor Yes" />180 Sponsorship&nbsp;<input tabindex="1" type="radio" name="Patron Sponsor 360" value="Family Sponsor Yes" />&nbsp;Patron $360&nbsp;<input tabindex="1" checked="checked" type="radio" name="Family Sponsorship" value="No" />&nbsp;No Sponsorship</p>

<p><input tabindex="1" type="radio" name="Will Mail Check" value="Will Mail Check" />I prefer to pay with Check. I will mail a check to Chabad of Peabody to PO Box 2154, Peabody MA 01960 (space is limited so your check is your reservation)</p>

<p><input tabindex="1" type="radio" name="PayPal" value="PayPal" />&nbsp;I prefer to pay with paypal. <strong>(Please submit this form then <a target="_blank" href="/Article.asp?AID=160760">click here to be linked to our paypal page</a>.)</strong></p>

 

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