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Florence Nightingale

Order Form

QTYITEM #DESCRIPTIONSIZE / STYLEPRICETOTAL
  A1005 Lady with the Lamp mug Tuxedo, Regular 15.00  
  A1025 Lady with the Lamp Beer Glass 16 oz 15.00  
  A1025 Lady with the Lamp Beer Glass 20 oz. 17.00  
  A1006 Lady with the Lamp T-shirt S M L XL 15.00  
  A1006 Lady with the Lamp T-shirt XXL 17.00  
  A1007 Lady with the Lamp poster   15.00  
Send to:
Country Joe McDonald
P.O. Box 7064
Berkeley, CA 94707, USA
Subtotal _______
Add $5 for shipping & handling        
($8 outside US) _______
TOTAL _______
Please print your name and address clearly so that Country Joe can read it!
Ship to: Name ________________________________________________
Street Address ________________________________________________
________________________________________________
City ________________________________________________
State/Province ________________________
Postal code ________________________
Country ________________________
 
Please inscribe item(s) to: ________________________________________________
________________________________________________

I wish to pay by:

__ Check or money order. Make payable to Country Joe McDonald. (We regret that we can only accept US cash and US checks due to the exorbitant fees US banks charge for handling other types. We apologize to our international customers.)

__ VISA __ Mastercard

Credit Card No. _____________________________________ Expiration Date _________