Dysautonomia Foundation Gift Baskets

 
  To order Celebrations Gift Baskets, please fill out the form below: 
 
 

Purchaser:
First Name:  
Last Name:
Address:      
                    
City:             State: ZIP:
Phone:        - -
Email:        
 
 
I would like to order Celebrations Gift Basket(s) for (state occasion):  
 

 
   Send basket(s) to my address above -OR-
 
  Check here if you are ordering a gift
 
Gift Recipient:
First Name:  
Last Name:
Address:      
                    
City:             State: ZIP:
Phone:        - -
Gift Message:
 
 

 
 

Shipping: Choose: USPS PRIORITY MAIL $7.50/package 
                    -OR-       USPS PARCEL POST $5.50/per package
 
Number of baskets at $25 each =  $
                    Plus Total Shipping costs =  $

                        Total Amount Enclosed =  $

 

Please make checks payable to: Dysautonomia Foundation, Inc.
 

 
 

Ordering is easy!!!
 
1. Print out and complete this order form and return it to: 
Dysautonomia Foundation,
633 Third Avenue, 12th Floor,
New York, NY 10017
-or-
2. Copy this order form into an Email and send it to: celebrations@hotmail.com