American RSDHope RSD - CRPS - Reflex Sympathetic Dystrophy

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	Mail-In Order Form Please print this form, indicate the quantity for each item that you would like to purchase, and mail the completed form to the address at the bottom of this form. You must complete and sign the "Authorization" section for us to process your order. Thank you for supporting American RSDHope! Billing Information This information must match your credit card's billing information First and Last Name:    Address:        City, State and ZIP:    Country:    Area Code & Phone:  (        ) Email Address:    Shipping Information Leave this section blank if we should ship to your billing address First and Last Name:    Address:        City, State and ZIP:    Country:    Area Code & Phone:  (        ) Email Address:    Credit Card Information Please double check your credit card number and expiration date Card Number:    CSC: (the 3 digit number on the back of your card)   Expiration (mo/yr):    Name on the Card:    Authorization I certify that I am at least 18 years of age and I agree to pay the below total amount in accordance with the cardholder agreement. Signature    Printed Name:    Date:    This product is not available White Sweatshirt Large Red RSD Logo - Save $9.00   Medium   $15.00 each   2X Large   $17.00 each DONTATIONS TO AMERICAN RSDHOPE - GENERAL FUND   Donation - (General Fund) $5 Units   $5.00 Each   Donation - (General Fund) $10 Units   $10.00 Each   Donation - (General Fund) $25 Units   $25.00 Each   Donation - (General Fund) $50 Units   $50.00 Each   Donation - (General Fund) $100 Units   $100.00 Each   Donation - Bronze Level $1,000   $1,000.00 Each DVD RSD CRPS- CONFERENCE SET OF THREE DVD'S   CONFERENCE DVD SET   $25.00 Each Maroon T-Shirt CRPS / RSDS Awareness Ribbon   Medium CRPS/RSDS T-shirt   $17.00 Each   Large CRPS/RSDS T-shirt   $17.00 Each   X-Large CRPS/RSDS T-shirt   $17.00 Each   2X Large* CRPS/RSDS T shirt   $20.00 Each KEY RINGS - CRPS/RSD AWARENESS - $5   Key Ring - Silver   $5.00 Each test Maroon CRPS/RSDS Sweatshirt with Awareness Ribbon   Maroon Sweatshirt Medium   $20.00 Each   Maroon Sweatshirt Large   $20.00 Each   Maroon Sweatshirt X-Large   $20.00 Each   Maroon Sweatshirt 2XL   $22.00 Each   Maroon Sweatshirt 3XL   $22.00 Each PORTABLE FLASH DRIVE - 12B MB - PC OR MAC   PORTABLE FLASH DRIVE   $8.00 Each RSD / CRPS AWARENESS RIBBON AUTO MAGNETS - GROUP   Magnets - Group rate - 10-Pack   $55.00 Each NATIONAL RSD / CRPS AWARENESS RIBBON AUTO MAGNETS   RSD Awareness Ribbon Auto Magnets   $6.50 Each   Magnets - Group rate - 10-Pack   $55.00 Each Blue T-Shirt Blue Ribbon Front & Back   Medium Blue T-Shirt - Ribbon/Back   $17.00 Each   X-Large Blue T-Shirt - Ribbon/Back   $17.00 Each   2XL Navy T-Shirt   $20.00 Each   3XL- Navy T-Shirt   $20.00 Each NATIONAL CRPS/RSDS AWARENESS BRACELETS - NEW LOOK!   BRACELET - SINGLE   $6.00 Each   BRACELETS - PACK OF 10 BRACELETS   $50.00 Each   BRACELETS - PACK OF 20 BRACELETS   $90.00 Each   BRACELETS - PACK OF 50 BRACELETS   $212.50 Each DONATIONS - HOPE FOR TOMORROW - RESEARCH FUND   Hope for Tomorrow Research Fund ( $5 Units)   $5.00 Each   Hope for Tomorrow Research Fund ( $10 Units)   $10.00 Each   Hope for Tomorrow Research Fund ( $25 Units)   $25.00 Each   Hope for Tomorrow Research Fund ( $100 Units)   $100.00 Each   Hope for Tomorrow Research Fund ( $500 Units)   $500.00 Each RSD / CRPS AWARENESS BRACELETS - NEW! GROUP RATE   BRACELETS - PACK OF TEN BRACELETS   $50.00 Each   BRACELETS - PACK OF 20 BRACELETS   $90.00 Each   BRACELETS - PACK OF 50 BRACELETS   $212.50 Each Blue Sweatshirt   MEDIUM   $29.00 Each   LARGE   $29.00 Each   X LARGE   $29.00 Each   2X   $31.00 Each CRPS / RSDS BROCHURES   10 Pack   $4.00 each   20 Pack   $7.50 each   50 Pack   $18.00 each   100 Pack   $34.00 each CRPS / RSDS BROCHURES - GROUP RATE   50 pack   $18.00 Each   100 Pack   $34.00 Each NATIONAL RSD AWARENESS PIN - GROUP RATE   Pin - Group Rate Ten-Pack   $35.00 Each Dragon Sweatshirts Adult & Children Sizes!   Children's S (6-8)   $29.00 Each   Children's M (10-12)   $29.00 Each   Children's L (12-14)   $29.00 Each   Medium   $29.00 each   Large   $29.00 Each   X Large   $29.00 Each   2X Large   $31.00 Each RSD CRPS AWARENESS PIN   Pin   $5.00 each   Pin - Group Rate Ten-Pack   $35.00 Each CARABINER KEY HOLDER   Carabiner Key Holder - Red   $4.00 Each   Carabiner Key Holder - Green   $4.00 Each   Carabiner Key Holder - BLUE   $4.00 Each WRITING PENS   Writing Pens   $2.25 Each   Writing Pens - 10 Pack   $20.00 Each   Writing Pens - 30 pack   $55.00 Each Please mail the completed form to: American RSDHope P O Box 875 Harrison, Maine 04040 Please be sure that you have signed the "Authorization" section. Thank you again for supporting American RSDHope!
	RSDHope is a project of American RSDHope, a 501 (c) (3) non profit organization Copyright © 1997-2010 American RSDHope Last updated 7/30/2010