Order Form

1940 Indian Chief

Please print out form and fax or mail it to us.

Suggested donation for tickets:
1 for $3.00
2 for $5.00
5 for $10.00
12 for $20.00
50 FOR $50.00

Personal Checks, Money Orders, Visa, MasterCard accepted (please do not mail cash)

Name: _____________________________________

Address: _____________________________________________

____________________________________________________

Phone Number: _______________

Visa/Mastercard #:________-________-_______-________ Exp. Date____/____/____

Number of Tickets: ____________

Total Enclosed: _______________

Please provide a self-addressed, stamped envelope.

Mail orders to:

Florida Lions Conklin Center for Multihandicapped Blind
405 White Street
Daytona Beach, FL 32114
Phone #: (904) 258-3441
Fax #: (904) 258-1155



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