PLEASE READ BEFORE YOU BEGIN:

2. Honoree Name*
4. Branch of Service:*
6. Rank:*
8. Veteran or Active Duty? (please select one)*

   1. Veteran

   1. Active Duty
10. Contact Name (payee):*
12. Relationship:*
14. Contact Phone #1:*
16. Contact Phone #2:
18. Contact Email:*
20. Contact Address:*
22. City:*
24. State/Zip Code:*
26. Please select how you would like to process payment.*
    -- Select One --I plan to pay in person with cash or Credit / Debit Card at the La Habra Community Center (101 W. La Habra Blvd., La Habra, CA 90631)I plan to pay with check. (Please make checks payable to City of La Habra.Please call me to process payment a credit card / debit card over the phone.

    Forms of Payment: 

    Cash - You can pay in person at the La Habra Community Center (101 W. La Habra Blvd., La Habra, CA 90631)

    Check - Checks can be mailed or brought in person to the La Habra Community Center La Habra Community Center (101 W. La Habra Blvd., La Habra, CA 90631)

    Credit / Debit Card - Staff will call you to process payment over the phone or you can pay in person at the La Habra Community Center (101 W. La Habra Blvd., La Habra, CA 90631)

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28. 1. Receive an email copy of this form.
29. Email address

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30. Submit

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