BESO MEDAL ORDER FORM

Medals cost $15.00 and are shipped priority.

Please complete the following items.

NAME OF UNIVERSITY *

COMPLETE NAME OF RECIPIENT *

PLEASE PROVIDE THE ADDRESS YOU PREFER THE MEDALS BE SHIPPED TO. (USUALLY UNIVERSITY ADDRESSES TAKE LONGER TO RECEIVE) *

CITY *

STATE *

ZIP *

PHONE NUMBER *

EMAIL ADDRESS *

Please mail me (state quantity) medals. *

Payment Information

Credit Card Type *

VISA

Mastercard

AMERICAN EXPRESS

DISCOVER

CREDIT CARD NUMBER *

CVS CODE *

Exp. Date(mm/yy) *

Cardholder's Name *