2019 KHB Day Registration

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Your credit card information is required. All bellow items (except garbage bags) must be returned, including gloves and vests. An invoice will be issued for any damaged or missing tools, and the amount will be deducted from the credit card. KHB will discard the credit card information after tools are returned. A price sheet for tools and supplies will be provided upon confirmation on your request.

Credit Card Type *

MasterCard Visa

Credit Card Number *

Expiration Date *

CVC # *

3 Digits on the back

What District will your clean-up/project be in? *

Location of Clean-Up/Project *

Number of expected volunteers *

What will your project include? *

Litter Clean-Up Illegal Dumpsite Clean-Up Beautification Other

Please describe your project. *

KHB Supply and Tool Request

Tool and Supply Request