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____________________________________________ Name ____________________________________________ Address ____________________________________________ City State/Province Postal Code ____________________________________________ ___ Check enclosed (payable to ACTL Foundation in U.S. Dollars) ___ Visa ___ Amex ___ MasterCard 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 ______________________________________ 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 SUMMER 2023 JOURNAL 92