____________________________________________
Name
____________________________________________
Address
____________________________________________
City State/Province Postal Code
____________________________________________
Phone Email Address
___ Blue Neck Tie $150 x ___ = $_____
___ Blue Bow Tie $90 x ___ = $_____
___ Red Neck Tie $150 x ___ = $_____
___ Red Bow Tie $90 x ___ = $_____
___ Scarf $250 x ___ = $_____
Total $ _____
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___ Check enclosed
(payable to ACTL Foundation in U.S. Dollars)
___ Visa ___ Amex ___ MasterCard
__________________________
Name as it appears on card Exp. Date
______________________________________
Signature
Send Payment by Email: nationaloffice@actl.com
Send Payment by Fax: 949-752-1674
Send Payment by Mail: ACTL Foundation
1300 Dove Street, Suite 150, Newport Beach, CA 92660
With each purchase, the following contribution is made to the Foundation:
Bow Tie: $25 Neck Tie: $50 Scarf: $25
FALL 2022 JOURNAL 58
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