Print out this page and mail it to:

 150 S. Glenoaks Blvd.
 #9238
 Burbank, CA 91502

 Or you can fax it to  818-891-6001

Date of order: ___________

Name:  
Address:  
City:  
State:  
Zip Code:  
Phone Number:  
Fax Number:  
Email Address:  

 

Payment: American Express MasterCard Visa Check (enclose with order form)
Credit Card #:

 

 Expiration Date:
Name on Card:  

Card Holder's Signature: _______________________________________________

All orders in U.S. dollars.  Make checks payable to the Native American Caucus.

Item Name Size Quantity Price
       
       
       
       
       

Shipping and handling charges:  $0.00 - $25.00 = $5.00

                                            $25.00 - $50.00 = $10.00

                                            $50.00 - $75.00 = $15.00

                                            $75.00 - $100.00 = $20.00

                                            over $100.00 = 10% of subtotal

 Subtotal:  
Shipping:  
Total  

 

Notes or special instructions: