June 2010 PDM, Benjamin's Taunton
Name
Organization
Street Address
Address (Cont)
City MA CT RI NH NY ME VT NJ Zip Code
Phone
Email
PayPal Cash at Door Check at Door Presentation only
If you select PayPal you will have that option on the next page.
Please provide the names of all of the individuals attending:
Be sure to include yourself!!
In order to reduce SPAM and unwanted email please enter the numbers you see in the image to the right in the box below.