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Online Mass Request

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- Your Personal Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Mass Intention Information
  
  Name for Mass Intention REQUIRED Please fill out this field. Please enter valid data.
  
  Is the person named above deceased? REQUIRED Yes No Please fill out this field.
  
  Date for Mass Intention REQUIRED Please fill out this field. Please enter a date.
  
  Time for Mass Intention to be celebrated: REQUIRED Please fill out this field.
  
  Would you like for us to send a Mass Card? REQUIRED Yes No Please fill out this field.
  
  If 'Yes' to Mass Card, to whom are we sending the card? (include name and address). Please enter a date.
  
  Additional Notes/ Remarks regarding Mass Intentions: Please enter valid data.
- Credit Card Information
  
  Name as it appears on Card REQUIRED Please fill out this field. Please enter valid data.
  
  Card Number REQUIRED Please fill out this field. Please enter valid data.
  
  Month of Expiration REQUIRED Please fill out this field.
  
  Year of Expiration REQUIRED Please fill out this field.
  
  CCV [3-4 numbers in back of card] REQUIRED Please fill out this field. Please enter valid data.
  
  Billing Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- I agree that the information stated above is the Name, date, and time of the person whom I want Mass celebrated for.
  
  I agree that St. Helena Catholic Church will charge $10 to my debit/ credit card within 3-4 business days of my request.
  I Agree Please select this field.
- Your Initials REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
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