Name Tag Order Form

Date

Member Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Membership Type Info.

All members are given a name tag at no cost when joining the temple. If you lost or are requesting a new name tag, please complete the information below.

The cost of a replacement name tag is $12.00. It usually takes 2-3 weeks for the name tag to be made. Name tags will not be ordered until payment is made.

Enter name as you would like it to appear.*

How will you be paying?*

CheckCredit Card

Credit Card Total amount due

Please consider paying an additional $3.00 to cover the bank fees incurred when using a credit card*

Yes, I will be happy to pay an additional $3.00 to cover the bank feesNo thank you, charge my credit card the original amount

Please pay $12.00 to cover the cost of replacing your name tag. Please write "Name Tag" in the memo part of your check and mail it to:

Temple Beth El

5150 Peridia Blvd. East

Bradenton, FL 34203

Name tags will not be ordered until payment is received.

Amount being charged to Credit Card

USDMembership Dues 4010

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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