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ORDER FORM
Ashki
-- The FD Bear
Dysautonomia
Foundation Inc.
I would like to purchase:
#____ Ashki(s) @ $50 =
$ ______
Add $5.00 for shipping and handling (USPS Priority Mail):
$ 5.00 x #____ Ashki(s) =
$ ______
Total = $ ______
Payment method:
____Cash
____Check (payable to:
Dysautonomia Foundation Inc.)
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Purchased By
_________________________________________________
Last
Name
First Name
_________________________________________________
Street:
Apt/Bldg/Suite
_________________________________________________
City
State/Country
Zip Code
_________________________________________________
Telephone
Email
=====================================================
Please complete this section only if delivery is to a different
address:
Deliver to
_________________________________________________
Last
Name
First Name
_________________________________________________
Street:
Apt/Bldg/Suite
_________________________________________________
City
State/Country
Zip Code
_________________________________________________
Telephone
Email
=====================================================
Is this a gift? _____ Gift message:
=====================================================
Mail this order form, along with payment, to:
Lisa Joseph, 1 Lynch Court, Voorhees, NJ 08043
or
Copy this form into an email to: FD212DYS@aol.com
__________________________________________________
Dysautonomia Foundation Inc.
633 Third Avenue, 12th Floor, NY, NY 10017-6706
(212) 949-6644
www.familialdysautonomia.org
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