Centennial Merchandise Order Form

* Make checks payable to:    DPCA

Name: __________________________________________________

Address: ________________________________________________

City: ____________________________________________________

State: ___________________     Zip:   _________________________

Email: ____________________________________________________

Please note that some items will ship from different locations.

Number of Programs ______ x $20 each.   Total Programs $_______

Number of Pamphlets ______ x $10 each.  Total Pamphlets $_______

Number of Collections _____ x $20 each.   Total Collections $______

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Payment must be made in US Funds and drawn on a US bank. There will be a $25.00 service charge for any check not honored by the bank.

Print, complete, and mail this form along with your check/money order made payable to DPCA to:

Marsha Sheppard
1584 E. Red Tree Ct.
Draper, UT 84020 USA