Liztech Pin Order Form

Monroe County Ambulance Association

P.O. Box 10 Tannersville, Pa, 18372

570-629-2620

 

Dr. Peter Favini M.D. Paramedic Scholarship Fund

 

Order Form for Liztech Pins

 

Name: ______________________________________________________________________________________

 

Address: ____________________________________________________________________________________

 

Phone #: _____________________________________ Email: _________________________________________

 

COST PER PIN - $50.00

 

Quanity: _____________________________________ Amount Received: __________________________________

 

Payment type:

 

Check #: ________________ Please make checks payable to Monroe Co. Ambulance Association

Cash: __________________

Credit Card: _____________ Visa, Mastercard, American Express, and Discover are accepted.

 

Please allow 8 to 10 weeks for delivery.

_____________________________

 

Monroe County Ambulance Association 570-629-2620

 

Lixtech Pin Fundraiser

 

Amount paid: ___________________   Date: __________________

 

Authorized Representative: ________________________________