A&R Summer Picnic | LeaderNet

Credit Card Registration Form ONLY...if you are paying by check do NOT use this registration form

A&R Summer Picnic at La Bella Vista380 Farmwood Rd, Waterbury, CTAugust 30, 202411:30AM, Lunch opens at 12:30PM

$20.00 A&R Member $33.00 A&R Retiree

Name of A&R Employee

Home e-mail

Cell Phone #

# of Active A&R Member tickets at $20 each

# of Retiree Tickets at $33 each

Total Cost For All Tickets

Type of Credit Card

By checking this box, I am agreeing to allow A&R to process payment from my listed card for tickets to this event. The charge may appear on your bill as "Am. Fed of Teachers" rather than A&R.

Name on the Credit Card

Full Address Associated with the Credit Card

City associated with the Credit Card

State

ZIP Code associated with the Credit Card

Credit Card Number

Card Expiration Date - Use Format (MM/YY)

3 or 4 Digit Credit Card Security Code