The ARC Network Lapel Pin Order Form

FIRST NAME: LAST NAME: ADDRESS: CITY: STATE: ZIP: QUANTITY OF PINS ORDERED: (_____) x $5.00 + $1.50* = * $1.50 shipping & handling PHONE: (_____) FAX: (_____) EMAIL: PAYMENT TYPE (please circle): CHECK CREDIT CARD CREDIT CARD INFORMATION: TYPE OF CARD (please circle): VISA MASTERCARD CREDIT CARD NUMBER: CREDIT CARD EXPIRATION DATE: NAME ON CREDIT CARD :

If ordering by credit card, please print this form and FAX to: (858) 618-1088 If ordering by check, please print this form and mail (along with payment) to: The ARC Network 11650 Iberia Place, Suite 201 San Diego, CA 92128 I certify that the above information is true, correct and complete to the best of my knowledge. I authorize the ARC Network to charge my credit card in the amount stated above.. ____________________________________ ________________________ (Applicant Signature) (Date) Return to the ARC Network