Materials - Fish T-Shirt Order Form

CENTER FOR MEDICARE ADVOCACY, INC.
P.O. BOX 350
WILLIMANTIC, CT 06226

FAMOUS FISH T-SHIRT ORDER FORM

Please print out, complete and mail this
order form to the above referenced address.

NAME:_________________________________________________________________________________

ADDRESS:______________________________________________________________________________

PHONE #:_______________________________________________________________________________

Indicate Size of T-Shirt(s) - Small, Medium, Large or Extra-Large	# of T-Shirt(s) X $15.00 (each)	Total

PAYMENT METHODS:

CHECK: Please make check payable to the Center for Medicare Advocacy, Inc.
CHARGE: Circle One - MasterCard or Visa

ACCT #: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (must be 16 digits)
Exp. date: ________

Authorized Signature: ____________________________________________