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2. Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Phone*
12. Credit Card Number*
13. Expiration Date*
14. CVV Number*
16. Quantity of Patches*
17. Each patch is $10, with proceeds benefiting a local charity. Patches will be shipped in a flat-rate envelope at a cost of $7.95.
21. I authorized Leaps PX to charge my credit card for the above specified quantity of patches and $7.95 shipping.
23. Name*
24. Email*
26. Please contact patches@riversidesheriff.org with any questions.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field