14TH ANNUAL CHPAA GALAPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.RSVP and paid by October 19, 2024Name / Organization / Company *Email *Phone *Address *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNumber of Attendees1 Person – $125.002 Persons – $250.003 Persons – $375.004 Persons – $500.005 Persons – $625.006 Persons – $750.007 Persons – $875.008 Persons – $1,000.009 Persons – $1,125.00Multiple boxes can be selected to add up to your number of attendees.Number of Tables1 Table – $1,250.002 Tables – $2,500.003 Tables – $3,750.004 Tables – $5,000.005 Tables – $6,250.00Multiple boxes can be selected to add up to your number of tables. Note: 10 people per table. NOTE: You are selecting both the Number of Attendees and the Number of Tables. Make sure that is your intention. Please review the Total cost. Total *$0.00How would you like to pay? *Credit CardZelle to [email protected]CheckCashPlease be sure to Zelle your payment by 10/19/2024 or your reservation will be cancelled. Any questions, please contact Suki Thong (email [email protected], text 562-260-1757).Please make check payable to “CHPAA” and send to: 930 Pine Avenue Long Beach, CA 90813 For other arrangements, please contact Suki Thong (email [email protected], text 562-260-1757) by 10/19/2024 or your reservation will be cancelled.For cash payment, please contact Suki Thong (email [email protected], text 562-260-1757) by 10/19/2024 or your reservation will be cancelled.Credit Card *CardName on CardCommentsIf you prefer to sit with other guests, please specify their names here. We will try our best to accommodate, but we definitely cannot guarantee.Signature * Clear Signature Submit
