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BINA High School 420 Spotswood Avenue * Norfolk, VA 23517 * 757-627-2462 * www.binahighschool.com YOUR NAME ______________________________________

EMAIL_______________________________________________

YOUR ADDRESS________________________________________________________________________________________ PHONE ____________________________________ SELECT TYPE OF DEDICATION:  one “Day of Learning” $72

 two “Days of Learning” $100

 permanent dedication $1800

DATE OF DEDICATION (HEBREW OR ENGLISH DATE) ______________________________________________________________ HONOREE

_____________________________________________ THE OCCASION ________________________________ ____

DEDICATED BY (name as you wish to be listed)  CHECK ENCLOSED ACCOUNT NUMBER

________________________________________________________________________________

 CHARGE MY CREDIT CARD (VISA, MASTERCARD)

_______________________________________________

EXPIRATION DATE__________________________

BINA High School 420 Spotswood Avenue * Norfolk, VA 23517 * 757-627-2462 * www.binahighschool.com YOUR NAME ______________________________________

EMAIL_______________________________________________

YOUR ADDRESS________________________________________________________________________________________ PHONE ____________________________________ SELECT TYPE OF DEDICATION:  one “Day of Learning” $72

 two “Days of Learning” $100

 permanent dedication $1800

DATE OF DEDICATION (HEBREW OR ENGLISH DATE) ______________________________________________________________ HONOREE

_____________________________________________ THE OCCASION ________________________________ ____

DEDICATED BY (name as you wish to be listed)  CHECK ENCLOSED ACCOUNT NUMBER

________________________________________________________________________________

 CHARGE MY CREDIT CARD (VISA, MASTERCARD)

_______________________________________________

EXPIRATION DATE__________________________

BINA High School 420 Spotswood Avenue * Norfolk, VA 23517 * 757-627-2462 * www.binahighschool.com YOUR NAME ______________________________________

EMAIL_______________________________________________

YOUR ADDRESS________________________________________________________________________________________ PHONE ____________________________________ SELECT TYPE OF DEDICATION:  one “Day of Learning” $72

 two “Days of Learning” $100

 permanent dedication $1800

DATE OF DEDICATION (HEBREW OR ENGLISH DATE) ______________________________________________________________ HONOREE

_____________________________________________ THE OCCASION ________________________________ ____

DEDICATED BY (name as you wish to be listed)  CHECK ENCLOSED ACCOUNT NUMBER

________________________________________________________________________________

 CHARGE MY CREDIT CARD (VISA, MASTERCARD)

_______________________________________________

EXPIRATION DATE__________________________


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