Good Luck-Las Vegas Medallion Order Form

I would like to order:

0 Other 1 2 3 4 5 6 7 8 9 10 Silver Medallion(s) 0 Other 1 2 3 4 5 6 7 8 9 10 Gold Medallion(s)

Other Quantity: Other Quantity:

-------------------------------------AND / OR--------------------------------------------

0 Other 1 2 3 4 5 6 7 8 9 10 Silver and Gold Medallion set(s)

Other Quantity:

Prefix: Mr. Miss Mrs. Ms. Dr.

First Name:

Last Name:

E-Mail Address:

Daytime Phone #:

Billing Address:

Street:

City:

State/Province:

Zip/Routing Code

Country:

Shipping Address:

Same Different Than billing address.

First Name:

Last Name:

Street:

City:

State/Province:

Zip/Routing Code

Country:

Method of Payment:

*Select* PayPal Check / Money Order

Method of Shipment:

*Select* UPS - Ground UPS - Red (Next Day) UPS - Blue (2nd Day) UPS - Orange (3rd Day) U.S. Mail

Additional comments \ Note for gift receiver