THE PMA GIFT SHOP MAIL-ORDER FORM

Ship to:

Name: ____________________________________________________________

Address: __________________________________________________________

Address: __________________________________________________________

City, State, ZIP: ___________________________________________________

Item #1 Description: ________________________________________________

                            ________________________________________________

Item #1 Price  $________        Item #1 Quantity ________    Total Cost Item #1 $__________

Item #2 Description: ________________________________________________

                            ________________________________________________

Item #2 Price  $________        Item #2 Quantity ________    Total Cost Item #2 $__________

Item #3 Description: ________________________________________________

                            ________________________________________________

Item #3 Price  $________        Item #3 Quantity ________    Total Cost Item #3 $__________

Item #4 Description: ________________________________________________

                            ________________________________________________

Item #4 Price  $________        Item #4 Quantity ________    Total Cost Item #4 $__________

Item #5 Description: ________________________________________________

                            ________________________________________________

Item #5 Price  $________        Item #5 Quantity ________    Total Cost Item #5 $__________

Item #6 Description: ________________________________________________

                            ________________________________________________

Item #6 Price  $________        Item #6 Quantity ________    Total Cost Item #6 $__________

                                                                                    Total Cost This Order $_______________

Billing Information:

Payment Method:    Check _____       VISA ______         MasterCard ______

For Credit Card Billing:

Name, exactly as it appears on card: ____________________________________________

Credit Card Number ___________________________________________________________

Credit Card expiration date: ____________________________________________________

Address (as it appears on your billing statement): __________________________________

                                                                   __________________________________

                                                                   __________________________________

                                                                   __________________________________

Daytime Telephone Number: ____________________________________________________