Nevada Full Statehood - Video Tape(s) Order Form  (Please Print)

Ship To :
Street Address :
City & State : Zip :
Phone:(opt)                                             Email:(opt)
Quantity Description - Title Unit Price Total
       
       
       
       
       
       
       


Attach additional sheets if necessary

 Sub Total     
Discount  
Shipping     
Total     

For Mail Orders print this form, list titles desired and send with payment to:

Nevada Committee For Full Statehood
P.O. Box 656
Sparks, Nevada 89432

for credit card orders you can fax this form to: 775-356-0727

Credit Card Order Information
 Name on Credit Card (print)

 Type of Card  (circle one)      MasterCard         Visa            Discover   
 Card #                                                 Expiration Date

              Cardholder Signature______________________________

 

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