I want to treat myself and my children to a most special gift . I want to purchase leaves on the Rebbitzen Chana Tree

 

Name:

Payment Type:
Address: Credit Card #:
Home Phone: Expiration date:

Work Phone:

 Total amount

Cell Phone:

 E-mail:

I want to purchase Gold Leaves

@ $360 for myself

    $630 (myself and spouse)

 

      Name:

      Name:

 

I want to purchase Silver Leaves@ $36for children/grandchildren

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

x $36

x $360

    Total paid in installments

Amount of Leaves I would like to order:
Total amount that will be enclosed  $

Total amount to be charged  $