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ORDER FORM
INSTRUCTIONS
           
Year Level:
Selected Product:Rocker
Color:
First Name:
Last Name:
Anniversary Date:
Work Location:
Shipping Address: (not a P.O. Box)
Shipping City:
Shipping State:
Shipping Zip Code:
*Please supply an "active" email address below. It will be used to contact you with
alternatives to the item you choose if the model you order is unavailable.
E-mail Address:
Work Phone:
Home Phone:
Will you be attending the awards ceremony? (Yes or No):
If you are not home at the time of delivery, may we leave the package?:
Additional Comments:
click on the submit button once please...        
Questions about the gifts?
Please call customer service at: 1-800-423-3471.
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