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____________________________________________
Name
____________________________________________
Address
____________________________________________
City State/Province Postal Code
____________________________________________
___ Check enclosed
(payable to ACTL Foundation in U.S. Dollars)
___ Visa ___ Amex ___ MasterCard
55
JOURNAL
Phone
___ Blue Neck Tie ___ Blue Bow Tie ___ Red Neck Tie ___ Red Bow Tie ___ Scarf
Email Address
$150 x ___ = $_____ $90 x ___ = $_____ $150 x ___ = $_____ $90 x ___ = $_____ $250 x ___ = $_____
Total $ _____
__________________________
Name as it appears on card
Exp. Date
With each purchase, the following contribution is made to the Foundation: Bow Tie: $25 Neck Tie: $50 Scarf: $25
______________________________________ 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
