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ONLINE ORDER FORM

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Contact Information
First Name:
Last Name:
Phone Numaber 1   (xxx-xxx-xxxx):
Phone Number 2   (xxx-xxx-xxxx):
Email Address:

Event Information
Event Date:
 
Arrival Time:
Location Type:
Phone Number at Event:
Event Address:
Event City:
Event State:
Event Zip Code:
Event Type:
Package Type:
Male of Female Entertainers:
Number of Entertainers:
Guest of Honor Name:
Approximate Number of Guests:
Male or Female Guests:
Entertainer Request 1
Entertainer Request 2
Entertainer Request 3
Entertainer Request 4
Entertainer Request 5
Entertainer Request 6

Billing Information
Credit Card Number:   (xxxx-xxxx-xxxx-xxxx)
Expiration   (mm-yy):
Security Code:
Name as it Appears on Card:
Billing Address:
Billing City:
Billing State:
Billing Zip Code:
Comment/Requests:
Referred By:


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