w Merchandise Order Form w

Please complete this form, print it and send it to our office with payment by fax: (302) 778-1104, or by mail: 100 W. 10th St., Suite 1115, Wilmington, DE 19801.

Name
Street Address
Address (cont.)
City
State
Zip
Phone
Email

Item Description	Price Each		Quantity Ordered	Total Price
Pink Silk Scarf (36" x 36")	$75.00
Peach Silk Scarf (36" x 36")	$75.00
Silk Neck Tie	$50.00
Pink Diamond T-Shirt	$30.00
Lucinda Pin Skin Tone Preference: Light Medium Dark No Preference	$14.00
Pink Ribbon Note Cards (5 per pack)	$5.00
Merchandise Subtotal

Shipping & Handling
Silk Scarf, Neck Tie, and/or T-Shirt: $5 each
Pin(s): $3 (1-3 pins) or $5 (4 or more pins)
Note Cards: $1.50/pack
Shipping & Handling Subtotal

Merchandise and S&H Total
Payment Options		MC Visa AMEXCheck (Payable to DBCC)
Credit Card Number
Expiration Date
Signature

Delaware Breast Cancer Coalition, Inc.

100 W. 10th St., Suite 1115, Wilmington, DE 19801, (302) 778-1102; Fax: (302) 778-1104

540 S. Governor's Ave., Suite 200, Dover, DE 19904, (302) 744-6529, Fax: (302) 744-6143

Toll Free: (866) 312-DBCC (3222)