ORDER FORM
Take Part...Give FD Art
Proceeds benefit children and adults with Familial Dysautonomia. 
Thank you for your support!
Dysautonomia Foundation Inc.

Take Part…Give FD Art cards are sold in packages of 6 assorted designs: 
 
Single Pack:       1 Package for $15 or
Double Pack:     2 Packages for $25 (a $5 savings!)
 
I would like to purchase:
#____ Single Pack(s)  X  $15  =                                  $ _________
#____ Double Pack(s) X  $25  =                                  $ _________
 
Shipping (if applicable):
$0.90 per Single Pack   X  #____ Single Packs  =        $ _________
$1.80 per Double Pack  X  #____ Double Packs or
$3.85 for 3 to 6 Double Packs  =                                 $ _________
Over 6 Double Packs, please call for shipping charge   
 --------------------------------------------------------------------------------------------------
Total  =                                                                     $ _________
Payment method: 
__Cash
__Check payable to: Dysautonomia Foundation Inc.
   ___________________________________________________________
 
Name:
 
Street:
 
City:
 
State/Country:                                           Zip Code:        
 
Telephone:                                                Email: 
  ___________________________________________________________
 
Please complete this part if cards are to be mailed
 ____Send to my above address or
 ____Send to the address below: 
  
Name:
 
Street:
 
City:
 
State/Country Zip Code:
 
Addressee's Telephone:
 
Is this a gift? _____Gift message:
 
__________________________________________________________________
Mail this order form to: Elise Goldblat, 5 Far Hills Road, Springfield, NJ 07081 or 
Copy this form into an email to: egoldblat@aol.com  
 _____________________________________________________________________________
Dysautonomia Foundation Inc. 
633 Third Avenue, 12th Floor, NY, NY 10017-6706 
(212) 949-6644
www.familialdysautonomia.org