Date of Order: _______________
Quantity: ____________________ x $10.00 = Amount Due: __________________
Date Needed: _________________
Ship to: ________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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Phone:___________________________ E-mail: ______________________________
Visa, MasterCard, American Express, Discover: ________________________________
Expiration Date: _____________________________
Mail Order to: FASS
2441 Village Green Place
Champaign, Illinois 61822
Phone: 217-356-3182
Fax: 217-398-4119
E-Mail: Fass@assochq.org
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For use by FASS only:
Date Shipped: ________________________________
How Shipped: ________________________________