Van Paint Job - Salam Flwshp

Request from Hicham Chehab Acting Pastor, Salam Arabic Fellowship; Missionary, POBLO- Chicago

Contact Information * required

First Name*

Last Name*

Contact Phone*

Home Phone

Work Phone

Mobile Phone

Email*

Street*

City*

State*

Postal Code*

Your Church

Please tell us your church (i.e. Peace Lutheran, Lombard, IL) or church affiliation (Lutheran, Catholic, UCC [or none if applicable]). We use this for tracking purposes only. We just like to know who and where we are reaching. Thank you.

Enter a Dollar Amount in the "Quantity" Blank below...

If you choose to use the Pull-Down Arrow, you may select from the list to choose a Dollar Amount
- or - Type the Amount into the box

Quantity = Increments of $1.00.

If you have any questions, please call us at 866-455-6466

I Understand and Agree

Total

Quantity
Price Per Ticket	$1.00
Pay With
TOTAL	$0.00

Billing Information

Same As Above

NOTE: Address must match exactly what is listed with your card company.

Credit/Bank Card Information

Card Number
Expires
Card Code (3 or 4 digit code)