Thank you in advance for your support!

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* 1. Please enter your full name:

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* 2. Please enter your email:

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* 3. Please select an option from below:

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* 4. If you are choosing to RSVP, How many seats would you like to purchase? ($250 per person)

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* 5. If interested in becoming a sponsor, please select one of the sponsorship levels below:

View Sponsorship Levels Here

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* 6. Would you like your contribution to be in honor or in memory of someone?

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* 7. What is the total amount for this transaction?

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* 8. What is your method of payment?

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* 9. What is the name of the card holder?

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* 10. Please enter the credit card number:

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* 11. Please enter the expiration date for this card:

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* 12. Please enter the CVV code on the back of your card:

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* 13. Please enter the billing address associated with this card:

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* 14. I would like to cover the 2.9% fee associated with processing my credit card payment.

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* 15. By submitting this form I allow The Melissa Institute for Violence Prevention & Treatment to process my credit card for the amount specified above. If paying by check, by submitting this form I agree to send payment for the amount specified above to 1507 Levante Avenue, Suite 331, Coral Gables, FL 33146.

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