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Upstate NY Chapter Store - 6/15/2007
 
MS Movement Marker - $2.00 each
Store Marker

MS Movement Clip - $2.00 each
Store Clip

MS Movement Bracelet - $5.00 each
Store Bracelet

Please print this form and fill in the information.

Please mail this form to:
National MS Society
Upstate New York Chapter
1650 South Avenue, Suite 100
Rochester, NY 14620-3901

Fax: (585) 442-2817
To pay on a credit card, please call 1.800.FIGHT MS.

Please let us know your mailing address.

Name:                                                                       
Mailing Address:                                                                       

                                                                      

                                                                      

Phone #:  (         )                                                          
E-Mail Address:                                                                       

Please indicate the amount you want below.

Item Price Quantity Cost
(Price x Quantity)
MS Movement Marker $2.00 $
MS Movement Clip $2.00   $
MS Movement Bracelet $5.00 $
 
Totals:
Quantity
 
    Cost
$