WIC Anniversary Lapel Pin Order Form

WIC Anniversary Lapel Pin Order Form

Please submit this completed form by emailing [email protected], faxing to 202-387-5281, or mailing to: NWA, 2001 S Street NW #580, Washington, DC 20009. Your order will be mailed once payment is processed. WIC 40th Anniversary Lapel Pin: Pin is 3/4” in diameter, blue and gold. (image not actual size)

Order Quantities ($4.89 each)

Shipping & TOTAL Handling Fee

5

$2.50

$26.95

10

$2.86

$51.76

15

$3.22

$76.57

25

$5.25

$127.50

40

$5.70

$201.30

Order Selection

SHIPPING INFORMATION Name ______________________________________________ Title _________________________ Organization _______________________________________________________________________ Address ___________________________________________________________________________ City ______________________________________________ State ________ Zip _______________ Phone ______________________________ Email__________________________________________

PAYMENT INFORMATION Payment Method: Purchase Order Credit Card:

Visa

Check

Amount______________________ Check #____________________

Purchase Order #___________________________________________________ Mastercard

American Express

Discover Card

Credit Card # _________________________ Expiration ______ CVC (3-4 digit security code) _______ Name as it appears on card ___________________________________________________________ Signature __________________________________________________________________________