9th Annual Westchester Fall Fashion Show Thursday, November 21, 2019 • 11:00 am - 2:30 pm Orienta Beach Club • 1054 Walton Avenue • Mamaroneck, NY 10543 • (914) 698-1900 Online Registration Tickets @ $150 each; # of Tickets: Choose: 0 1 2 3 4 5 6 7 8 9 10 Table of 10 - $1,500 Guest Names: I am unable to attend but would like to made a donation in the amount of $   Method of Payment General Information Email Address Last Name First Name Address Address 2 City State ----- Canada ----- Toronto Quebec Vancouver Ontario ----- United States ----- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Fax   Comments: Payment Information Credit Card Number 1 - Jan 2 - Feb 3 - Mar 4 - Apr 5 - May 6 - Jun 7 - Jul 8 - Aug 9 - Sep 10 - Oct 11 - Nov 12 - Dec / 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Name On Card CVV Security Code Billing Information Last Name First Name Address Address 2 City State ----- Canada ----- Toronto Quebec Vancouver Ontario ----- United States ----- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip RSVP by November 18, 2019

Prefer to pay by check?
Print this page and send it with your check made out to Kidney & Urology Foundation of America
63 West Main Street, Suite G, Freehold, NJ 07728


Federal Tax ID: 131-777-413

A note about website security: We take your personal information seriously and can assure you that all of your credit card data is fully secure and encrypted when being processed on our site. You should see the "https" prefix at the start of the web address in your browser, as well as your browser's lock icon, as soon as you reach any checkout page on the site. Both of these indicate that you are on a secure page.