Mr./ Mrs./ Ms.

First Name

Last Name

Mailing Address

Province/State

Country

Postal/Zip Code

E-mail address (Optional)

Qty

Description

Unit Price

Total

1¼” 22 kt Gold plated coin in presentation box

$ 20.00 (tax included)

$

1¼” Silver (nickel plated brass) in plastic capsule

$ 5.00 (tax included)

$

Office Use Only

Sub Total

$

Shipping & Handling

$

TOTAL

$

Make cheque or money order in Canadian funds payable to:

75^th Anniversary Committee - Amelia Earhart

(address above)

Shipping & Handling per Coin:

Gold :$12.00 (CDN)

Silver :$5.00 (CDN)

Add an extra 10% for each additional coin