The Rotary Club of Sedona
P.O. Box 2170, Sedona, AZ
86339
Phone: 928-284-0136 Fax: 928-284-2992 Email:
geoshell2@msn.com
Order
Form for the Paul Harris Bronze Sculpture
Rotary
International License Agreement #96-4B0124
To order by mail,
print this form, fill it out and mail to the address above.
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Date: ___________________________________ |
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___Phone Order ____ Mail Order ____ Other ___________________________________________________ |
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Name: ___________________________________________________________________ |
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Address: _____________________________________________________________________________________ |
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City: _________________________ State: _______ Country (if not USA) _______________________________ |
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Shipping Address if different (cannot ship to PO Box) |
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______________________________________________________________________________________________ |
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Telephone: ______________________________________ |
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______ Paul Harris Sculptures @ $199.00 US |
$ __________ |
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Shipping - $10 in US Call or Email for out of US |
$ __________ |
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TOTAL |
$ __________ |
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A personalized plaque (up to 3 lines of text) will be enclosed with the sculpture at time of shipment |
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____ Check here if you desire a brass plaque with no engraving |
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Name: _________________________________ |
Name of Rotary Club: ________________________________ |
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Name
of Paul Harris Fellows: |
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______________________________________________________________________________________________ |
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Method of Payment: ____Cash ____ Check ____ Visa Card ____ Master Card |
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Credit Card Number ________ ________ ________ ________ Expiration: ________ / ________ |
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Make check payable to Rotary Club of Sedona |
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Complete this form and mail or FAX to the above address. Call or Email for additional information. |
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