Nctbushform

	C.T. Bush Order Form Texas –Oklahoma Kiwanis Foundation 624 Six Flags Dr. Suite 265 Arlington, Texas 76011-6342		Presentation date ___________ and location ___________
Order Date ___________________
Recipient Name:___________________________________________ Member ID #__________________
City ____________________________________________ State _____ Zip ______________
Recipient’ s Kiwanis Club name ____________________________ Key #__________
Donor Name_____________________________________		[FrontPage Save Results Component] Donor Information Member ID # ________________ Division # ___________________ Club Name __________________ Key # ______________________
Donor Address___________________________________
City_______________________ State______Zip_______
Club President___________________________________
Ship to:_________________________________________ _________________________________________ City_______________State_______________Zip_______ Phone No:__________________________
PAYMENT
[FrontPage Save Results Component] Check for $500.00 made out to the Texas Oklahoma Kiwanis Foundation enclosed Visa Mastercard Amount to Charge $ ____________ Credit card Number ________________________ Exp Date (Mo)____ (Year)____ Cardholder’s name____________________________________________ Signature __________________________________________ Return form to: Texas Oklahoma Kiwanis Foundation C.T. Bush Request 624 Six Flags Dr. Suite 265 Arlington Texas 76011-6342 817-640-7711 Fax 817-649-1905