Association of
Shrine Oriental Bands of
Ladder of Smiles
fund-raisers order form
Please use your
browser print function and send this form with your check (in U.S. funds) to:
W.
Michael Hartup
I
wish to order ___ “SILENT MESSENGER” statue(s)
The statues are
$30 each which includes shipping. Please
send the statue(s) to the address indicated below:
Name:
_________________________________________________________
Address:________________________________________________________
City:____________________________________________________________
State /
Phone #: (_____) _______ -
___________
Email address:____________________________________________________