35th Anniversary Celebration of Life Gala with Dinesh D’Souza Saturday, September 28, 2019 6:00 pm Fort Worth Omni Hotel 1300 Houston St, Fort Worth, TX 76102 $20 Valet / $18 Self Park **Please indicate the number of reservations you & your guests will need.I would like to purchase* Single Reservation Tickets Table Reservations (Seats 10) Underwriter Reservation I will NOT be able to attend the Celebration of Life Gala, but would like to make a one time tax deductible gift Number of Single Reservations*Early bird pricing of $75.00 until September 1st! $85.00 after September 1st. Price: $75.00 Quantity: Number of Tables, Seats 10*Early bird pricing of $750.00 until September 1st! $850.00 after September 1st. Price: $750.00 Quantity: Underwriter*Please choose an underwriter reservation$750 (Includes: Dinner for 2)$1,500 (Includes: Table for 10)$2,500 (Includes: Dinner for 10; Valet Passes)$5,000 (Includes: Dinner for 20; Valet Passes)$10,000 (Includes: Dinner for 20; Valet Passes)$25,000 (Includes: Dinner for 20; Valet Passes)$50,000 (Includes: Dinner for 30; Valet Passes)Donation Amount* I'd like to cover all transaction fees so 100% of my donation goes to Metroplex Women's Clinic*YesNoTotal Fees Price: $0.00 Row Quantity CalculatorRow Quantity CalculatorRow Quantity Calculator Valet*Please specify quantity of valet passes needed.Number of Valet Passes*Guest Names*Reservations required. Please list individual names. Call 817.299.9599 with questions.Do you want to enter guest names now?*YesNo, I'll call later to provide guest namesSingle Reservation Guest Names* Table Reservation Guest Names* Underwriter $750 - Guest Names* Underwriter $1,500 - Guest Names* Underwriter $2,500- Guest Names* Underwriter $5,000 - Guest Names* Underwriter $10,000 - Guest Names* Underwriter $25,000 - Guest Names* Underwriter $50,000 - Guest Names* Billing InformationTotal $0.00 Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which church do you attend?*Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.