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Secure Payment Form

Ticket Purchase Summary:
Transaction Date: 11/22/17
[Insert Quantity in the Boxes Below & not "$" Amount.]
 
Blue Raffle Tickets - 1 ticket $1.00:
6 tickets - $5.00:
12 tickets - $10.00:
25 tickets - $20.00:
60 tickets - $50.00:
125 tickets - $100.00:
Red = Food and Carnival Tickets - $1.00:
Orange = 50/50 - $1.00:
Total Charge $:
           
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
   
Purchaser Information:
First Name:
Last Name:
Phone Number:
Email Address:
     
   


Please Note: A record of this transaction will be sent to your email shortly. Please print and present at BMN 9/16/2017 to redeem your food and raffle tickets. Thank-you!

I.A.P.A Santa Barbara , CA
www.iapasb.com