Tributes & RSVP 1. Reservations Full Name* First Name Last Name Phone Number* Area Code Phone Number E-mail* Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Company Name Will attend Gala reservation is included with half page (or higher) journal ad. Gala dinner reservation ($180 per person) Number of Gala Dinner Reservations (not included in journal ad) $180 per person Please list dinner guests below: (If not attending write N/A above) Unable to attend But would like to place an ad in the tribute journal 2. Tribute Opportunities Select One: Event Host (Includes event host dedication, a room dedication in the Hospitality House, back-cover journal page, a private reception with Dennis Prager and two reserved tables) [$100,000] Champion of Hope (Includes a room dedication in the Hospitality House, a champion of hope journal page, a private reception with Dennis Prager and two reserved tables) [$50,000] Founders of Hope (Includes Shabbat table dedication in the Hospitality House, founder of hope journal page, a private reception with Dennis Prager and two reserved tables) [$36,000] Pillar of Hope (Includes a Shabbat seat dedication in the Hospitality House, a pillar of hope journal page, a private reception with Dennis Prager and one reserved table) [$18,000] Diamond of Hope (Includes a dedication of two gala dinner tables, diamond of hope journal page, a private reception with Dennis Prager and one reserved table) [$10,000] Platinum (Includes a dedication of one gala dinner table, a platinum journal page, a private reception with Dennis Prager and six reservations) [$5,000] Gold (Includes gold journal page and six reservations) [$3,600] Ruby (Includes ruby journal page and four reservations) [$1,800] Full Page (Includes a full page journal ad and two reservations) [$1,000] Half Page (Includes a half page journal ad and one reservation) [$500] Choose your own contribution amount $ Write the text of your Event Journal ad here: All camera-ready designs, including business cards, must be submitted in hi-res JPEG, PDF or PSD format to [email protected] . Designs can be either black and white or full color. You can also submit your ad text using the designated box above. Full Page 8 1/2" x 5 1/2" | Half Page 4 1/4" x 5 1/2" | Quarter Page 4 1/2" x 2 3/4" 3. Payment Total $0.00 Payment Credit Card Visa MasterCard American Express Discover Credit Card Type Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Expiration Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.