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Centennial History Order Form NAME ____________________________________________________________ STREET ADDRESS _________________________________________________ CITY/STATE _______________________________ ZIP CODE ______________ PHONE ____________________ E-MAIL ________________________________ I choose to pay by the following method: (check one) __________ Check (Payable to Delta Omicron International Music Fraternity) __________ Money Order (Payable to Delta Omicron International Music Fraternity) __________ Credit Card (Complete the information below) If paying by credit card, give the following information. VISA, MasterCard, or Discover in US FUNDS ONLY; a 4% surcharge applies to all credit card orders. Check one of the following options: _____ VISA _____ MasterCard _____ Discover Name as imprinted on the Card _______________________________________ Card Number ______________________________________________________ Expiration Date ____________________________________________________ Signature _________________________________________________________ Mail this form and your payment to: Jennifer Klafeta, National Treasurer, 665 Pembridge Lane, Unit C, Prospect Heights, IL 60070. |