Contributor Information

Will you be attending our Annual IPA Comedy Night? *

Yes, I would like to attend

No, I cannot attend but would like to purchase donation tickets

First Name *

Last Name *

Email Address *

Employer/Organization *

Occupation *

Address 1 (PO Boxes Not Allowed) *

Address 2

City *

State *

Zip Code *

Phone *

Fax

Attendee Information

Tickets (please enter quantity below - up to 5 tickets can be purchased at a time)
Ticket includes dinner, open bar, and entertainment.

	Pharmacists/Friends Ticket ($201.00 ea)	(62 remaining)
	Student Ticket ($75.00 ea)	(20 remaining)

Total Number of Attendees (i.e. You may choose to support the event by purchasing 5 tickets, but only have 3 guests attend the event. Please indicate 3 or # of ATTENDEES ONLY in this field.) *

Attendee Information (up to 5 attendees can be entered at a time)

	First Name	Last Name	Email Address
Attendee #1	First Name	Last Name	Email Address
Attendee #2	First Name	Last Name	Email Address
Attendee #3	First Name	Last Name	Email Address
Attendee #4	First Name	Last Name	Email Address
Attendee #5	First Name	Last Name	Email Address

Donation Tickets (Unable to Attend)

Donations Tickets - Unable to Attend (please enter quantity below - increments of $201)

Comedy Night Donation ($201.00 ea)

(218 remaining)

Payment Information

Current Total:

$0.00

Please note: All donations and proceeds through this event are donations to the California Pharmacists Political Action Committee (CPh-PAC) and are considered political donations. Pursuant to state law, all donations are reported to the California Fair Political Practices Commission. Contributions to CPh-PAC are not deductible as charitable contributions for federal income tax purposes.

If paying by check, please make check payable to: CPh-PAC, ID# 1291777

Mail to: CPh-PAC 4030 Lennane Drive Sacramento, CA 95834