Name      Address 

City          State     

Zip Code       Area Code/Phone      Date

Method of Payment            Check            Certified Check            Money Order

 Item #     Quantity                           Description                             Unit Price        Total

                                                                                                         Sub-Total       

                                                                                      Shipping & Handling     

                                 ($4.95 for ONE plaque and $1.50 for EACH additional plaque)

                                                                                                        Sales Tax            

                                                                              (Illinois Residents add 6.75%)

                                                                                                                 Total