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Application Nameorbeon Form Namepta-remittance Form TitleOrbeon Demo: Springfield PTA Remittance Form Form DescriptionThis is a remittance form for the Springfield PTA Council. { "inline" : true, "hidden_input" : false, "language" : "en", "statusbar" : false, "menubar" : false, "plugins" : "lists link", "toolbar" : "bold italic | bullist numlist outdent indent | link", "browser_spellcheck" : true, "encoding" : "xml", "entity_encoding" : "raw", "forced_root_block" : "div", "visual_table_class" : "fr-tinymce-table", "skin" : false, "convert_urls" : false, "sandbox_iframes" : true, "convert_unsafe_embeds": true }

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Name of PTA UnitMissing or incorrect value

Unit NumberMissing or incorrect value

Address of UnitMissing or incorrect value

Submitted byMissing or incorrect value

Phone (555) 555-5555 Missing or incorrect value

PositionMissing or incorrect value

EmailMissing or incorrect value

Date Submitted Missing or incorrect value

Check # Missing or incorrect value

Comment

Per Capita Dues (due monthly)

Members Count Missing or incorrect value

Fee per Member

Member Dues

One time annual Council Dues (due 11/1)

Annual Dues

Annual Council Dues

Donation (optional)

Total Check Amount

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Orbeon Form Builder

Orbeon Demo: Springfield PTA Remittance Form

Unit Details

Submission Details

Amounts