A&R Summer Picnic

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

A&R Summer Picnic at La Bella Vista
380 Farmwood Rd, Waterbury, CT
September 1, 2023
11:30AM, 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. *

I agree

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 *

A&R Summer Picnic

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, CTSeptember 1, 202311:30AM, Lunch opens at 12:30PM

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

A&R Summer Picnic at La Bella Vista
380 Farmwood Rd, Waterbury, CT
September 1, 2023
11:30AM, Lunch opens at 12:30PM

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