Calendar Dedication Page

$18 for each dedication. $100 for 6-8

Number of Dedications *

1 - $ 18.00

2 - $ 36.00

3 - $ 54.00

4 - $ 72.00

5 - $ 90.00

6 - $ 100.00

7 - $ 100.00

8 - $ 100.00

Total Amount

Your Special Dates

Please enter YOUR information in the first fields. In the LAST field, fill out your DEDICATION INFORMATION (birthdays, Yahrzeits, anniversaries, graduations etc)

YourFirst Name *

Your Last Name *

Your Email *

Phone *

Please be sure to write your FULL street address and apartment number if applicable

Street Address *

City (Primary)

State (Primary)

Postal Code (Primary)

Instructions: For Each Dedication 1) Please specify the occasion you are dedicating (Birthday/Yahrzeit/Anniversary/Graduation etc.) and the exact dates (MM/DD/YEAR) 2) Include the FULL NAME(S) and the RELATIONSHIP(S) to you of the people you are honoring. 3) For Hebrew birthdays and Yahrzeits indicate if birth or passing was BEFORE Sunset or AFTER. Please specify their Hebrew names and the Hebrew names of their mother and father's (if known).

Dedication Information for those you are honoring *

Authorize.net (Credit Card)

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Thank you for participating, the deadline for special dates in the calendar has passed.

CHABAD OF STAMFORD - JEWISH CENTER FOR LIFE AND LEARNING

info@stamfordchabad.org | 203-3CHABAD | 770 High Ridge Road Stamford, CT 06905-2308