TEMPLE BETH SHOLOM

HIGH HOLY DAYS 2009/5770

Registration Payment Summary and Receipt
(702) 804-1333 x100 • 10700 Havenwood Lane, Las Vegas, NV 89135 • Fax: (702) 804-1370

Date: _______________ Name: ________________________________________________________

Address: ______________________________________________________________________________
Daytime Phone:_______________________________ Email: _________________________________
Payment Method: _____ In Person _____ Mail _____ Fax _____ Phone
Please check the forms that are being turned in with your registration.

❑ Seating Registration ❑ Guest Seating ❑ Children’s Seating

❑ Children’s Program ❑ Kol Nidre ❑ Book of Memory
$__________ Past Dues and Security Please list name in Kol Nidre Book as:
____________________________________________________
$__________ Current Dues and Security
Payment information
$__________ 2009 Seating Registration
________ Check # _______________________________
$__________ 2009 Guests Seating
________ VISA ________ MASTERCARD
S __________ 2009 Children’s Seating __________________________________________________
(Credit Card Number)
$__________ 2009 Children’s Program
_______________________ _____________________
(Expiration Date) Security Code
$__________ 2009 Kol Nidre Appeal
__________________________________________________
$__________ 2009 Book of Memory Signature

$________ TOTAL
For Office Use Only
Number of Seats ________ ________ ________ ________ ________ ________
Special Accommodations needed _________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
SEAT #
________ ________ ________ ________ ________ ________ ________ _____