NIADA Conference Souvenir Doll
ORDER FORM

- Limited quantities available. Order now! Madison W. Bean $95.00 each Scruggs $50.00 each plus $5.00 shipping and handling per doll. (US addresses only) Print out this form and send check or money order payable to "NIADA, Inc." (US funds only). Complete the information at the bottom of the page for Mastercard or VISA purchases. Mail this entire form to: NIADA Souvenir Doll, Diana Rew, 8320 Maplewood St,. Lenexa, KS 66215

Ordering Information: (please indicate quantity) __ EA. NIADA 2000 Souvenir Doll -"Madison W. Bean" plus shipping $___ __ EA. NIADA 2001 Souvenir Doll -"Scruggs" plus shipping $___ TOTAL $ Enclosed:________ Name:______________________________________________________ Address:___________________________________________________________________ __________________________________________________________________________ Ph:_________________________ Fx:________________________Email:___________________________________ Complete the following information if paying by Credit Card. Please circle one: Mastercard / Visa Name as appears on card:_______________________________ Card number:________________________________ Expiration Date:______________________ Signature: ______________________________________ This order form must be included with your check or money order. Credit card orders may be faxed to: 913 888-5167. Please allow two to three weeks for delivery. Date Received: _____________ Order Sent: __________Check#: ________

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