
| FRONT | BACK |
![]() |
![]() |
| FIRST
NAME: |
MIDDLE
NAME: |
LAST
NAME: |
DATE:
|
| ADDRESS STREET: |
CITY: |
STATE: |
ZIP CODE: |
|
|
|
|
|
| NU Chapter of ΓΦΒ Little House | COST: | # ORDERING: | TOTAL CHARGE: |
| $24 | __________ | $__________ | |
|
|
Postage ($6 for 1; $9 for 2; $12 for 3 houses) |
__________ | $__________ |
| TOTAL with shipping: | $__________ | ||
| PAYMENT
METHOD: |
|||
|
VISA/MC:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ |
EXP DATE: __ __ / __ __ |
||
| or |
|||
|
CHECK: (make payable to: NU House100th
Birthday)
|
|||
| SEND
YOUR PAYMENT WITH THIS FORM TO: |
|||
| Mail: |
Patti Hallin Luse 979 Ascot Drive Eugene, OR 97401 |
Fax: | (541) 485-1072 |
| Email: |
pattiluse@comcast.net |