
| FRONT | BACK |
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| FIRST
NAME: |
MIDDLE
NAME: |
LAST
NAME: |
DATE:
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| ADDRESS STREET: |
CITY: |
STATE: |
ZIP CODE: |
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| NU Chapter of ΓΦΒ Little House | COST: | # ORDERING: | TOTAL CHARGE: |
| $20 | __________ | $__________ | |
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Postage ($6 for 1; $9 for 2; $12 for 3 houses) |
__________ | $__________ |
| TOTAL with shipping: | $__________ | ||
| PAYMENT
METHOD: |
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CHECK: (make payable to: Gamma Phi Beta)
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| SEND
YOUR PAYMENT WITH THIS FORM TO: |
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| Mail: |
Ann Henderson Kershner 34316 Deerwood Dr, Eugene, OR 97405 |
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| for questions pleas email: |
ann_kershner@hotmail.com | or call: 541-741-0271 | |