Casino Night Registration
3816 Caroline St. - Houston, TX 77581 7pm-12am
Full Name
*
Prefix
First Name
Last Name
Organization/Business
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Additional Attendees
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
Types of Sponsorship
Type of Sponsorships
Black Jack Table
Crap Table
Roulette Table
Donate
Purchase Sponsorship
My Products
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Vendor Table
$
250.00
Quantity
1
2
3
4
5
6
7
8
9
10
Donate/Sponsorship
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Individual Entry Fee
$
150.00
Quantity
1
2
3
4
5
Bronze Package
$
1,500.00
Silver Package
$
5,000.00
Gold Package
$
10,000.00
Platinum Package
$
15,000.00
Diamond Package
$
25,000.00
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Submit Form
Should be Empty: