• Security Credential - BADGE ORDER

  • Please submit names for each badge you purchased.  If more than 10, please submit additional form(s).

     

    Miss/Teen titleholder

    or

    Lone Star Princess

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  • Jotform Logo 2023 Teen Credentials Order FormConference Online Registration Form




    Primary Registrant's Full Name Jan Mitchell
    E-mail janm@misstexas.org
    Phone Number (214) 549-2003
    State Organization Affiliation Texas
    Relationship to Candidate State Organization
    First time to attend the Teen Competition? No
    Primary Registrant's Billing Address Street Address: 951 Greenside Drive
    Street Address Line 2: #7128
    City: Richardson
    State / Province: Texas
    Postal / Zip Code: 75080
    Country: United States
    Are you buying credentials for multiple people? Yes, I'm purchasing for multiple people
    How many additional credentials would you like to purchase (not including your own)? 2
    Additional Credential 1 First Name: Britan
    Last Name: Robertson
    Email: britan@misstexas.org
    Phone: 405-388-7391
    State Affiliation: Texas
    Relationship to Candidate: Teen Director
    First Time Attending Teen? (yes/no): no
    Additional Credential 2 First Name: Cherry
    Last Name: Hanes
    Email: cherryhanes@hotmail.com
    Phone: 872-670-7320
    State Affiliation: Texas
    Relationship to Candidate: Volunteer
    First Time Attending Teen? (yes/no): yes
    Please Note: Credentials are the property of the Miss America Organization and may only be used by the person to whom it is issued. Sharing of credentials is a serious security breach and will result in confiscation and removal of both parties from the event. Miss America Organization Officials can, at their discretion, revoke the use of a credential at any time. I understand and agree to the above statement
    Total Number of Credentials 3
    Total Credential Payment Calculation 150
    Payment Authorization
    Credentials are $50 each. (Amount: 150.00 USD)
    Total: $150.00
    Stripe customer ID: cus_M5ACYcSyggQyBt


    ==Payer Info==
    First Name Jan
    Last Name Mitchell
    E-Mail janm@misstexas.org

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