Wall Plaque Online Donation for Panida Theater

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Wall Plaque Donation Form

Wall Plaque Donation Form

The Panida Theater is raising funds to create a wall plaque with all of the names that were on the bricks.

1
Full Name* This field is required.
First Name
Last Name
2
E-mail* This field is required.
3
Phone Number* This field is required.
Area Code
Phone Number
4
Comments
5
Your Donation Amount
prevnext( X )
5.00
USD
10
USD
25
USD
50
USD
75
USD
100
USD
200
USD
Description
USD
+ OR enter a custom value
First Name
Last Name
Should be Empty:

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