| Enter the date each rank was earned in the boxes next to the rank names. If exact date is not known, enter month & year, or year only. | |||
| Use your browser's "Print" feature to print this form, sign it, and Fax or mail it to the address above. | |||
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| ORDER SUMMARY | |||||||||||||||
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| Billing Address | |||
| Parent's Name | Home Phone - - | ||
| Address 1 | City | ||
| Address 2 | State | Zip | |
| Cell/Wk Phone - - | |||
| Shipping Address (if different) | |||
| Name | Phone - - | ||
| Address 1 | City | ||
| Address 2 | State | Zip | |
| We must have a phone number for the shipping address. | |||
PAYMENT INFORMATION: | ||||||||
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CREDIT CARD INFORMATION: | ||||||||
| Name on Credit Card: | ||||||||
| First Name | Middle Name | Last Name | ||||||
| Please make sure that the Billing Address (above) is where the credit card statement is sent. | ||||||||
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| CREDIT CARD NUMBER: | EXPIRATION DATE: | SECURITY CODE: (on back of card) | ||||||
| Signature: ______________________________________________________________________________________ | ||||||||