2010 FPRA-OAC Image Awards Reorder Form

1. 2010 IMAGE AWARDS RE-ORDER FORM
Qty. Description Cost ea. Total
Grand All Image Award Pyramid $96.25
Grand Image Award Pyramid $82.50
Image Award Or Grand All Image Award $40.70
9”x12” Walnut Plaque w/Silver Image Coin Logo
Image Award, Grand Image Award, or Judges' Award 5"x7" $27.50
Walnut Plaque W/Laser Image Logo
Award of Distinction Certificate in 10 1/2" x 13" Walnut frame $27.50
w/Plexiglas (printed-complete)
Award of Distinction, Judges' Award, Image Award $5.75
Printed Certificate Only
*Shipping – Add $6.00 per item for delivery Subtotal
Allow 4-6 weeks for delivery Shipping
Send check (payable to FPRA), or place your 7% sales tax
credit card information below TOTAL
Award Division/Category__________________________________________________________________
Title of Entry____________________________________________________________________________
Names on Award (limit 3) ______________________ _____________________ __________________
Shipping Address (No PO Boxes) _______________ City _______________ State_________ Zip______
Credit Card Billing Address (if different) ________________________________________ Zip ______
Name _____________ Name on Card (if different)____________________ Telephone _________________
Type of Card ____________ Credit Card # ___________________________ Exp. Date______ / ______
Security Code (Visa, MC, Discover- last three digits on back of card – AmEx-four digits on front) ____________________________
Signature: _____________________________________________________________________________
Mail, fax or email the completed form to Jennifer Gammage no later than Friday, May 21, 2010 at 4:00 PM:
Jennifer Gammage
st
2200 West 1 Street
Sanford, FL 32771
Fax: (407) 321-3041
jgammage@cancercarecenter.md