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 BILLING ADDRESS:  SHIPPING ADDRESS, if different from  billing address:
NAME

 CREDIT CARD INFORMATION:
       

 PLEASE SEND ME THE T-SHIRTS SELECTED BELOW at $12.00 (USD) EACH
MEN'S Medium

MEN'S Large
MEN'S X Large

MEN'S 2X LARGE


WOMEN'S
Small
WOMEN'S
Medium
WOMEN'S
Large
WOMEN'S
XLarge
I JUICE band included
with each t-shirt
 
TOTAL # OF T-SHIRTS
Your credit card charge will show:
Dr. Peter G. Gorman, 11 Miller Rd., Mahopac, NY 10541. To pay by cheque, send cheque to above address.
8.375%
if applicable
All profits from t-shirt sales will be donated to charity.  (see below)
If larger quantities are needed, or
if you prefer to give your credit card over the phone, call  845-628-4900










ShIPPING COSTS USPS PRIORITY MAIL:
In the Continental US: 1 t-shirt - $4.95; 2-6 t-shirts - $10.35; 7-10 t-shirts - $13.95;
Canada and Mexico: 1 t-shirt - $10.95; 2-6 t-shirts - $25.95; 7-10 t-shirts - $32.95;
All other countries: 1 t-shirt - $12.95; 2-6 t-shirts - $41.95; 7-10 t-shirts - $53.95;