| Institution
Name: |
_________________________________ |
| Contact Person:
|
_________________________________ |
| Street Address: |
_________________________________ |
| City, State,
Zip Code: |
_________________________________ |
| Daytime Telephone: |
_________________________________ |
| Additional Quantity
Ordered: |
___________ (at
$100 each) |
| Total Amount
Enclosed: |
____________ |
PLEASE MAIL THIS
ORDER FORM
AND CHECK OR MONEY ORDER TO: |
Federal Deposit
Insurance Corporation
Department Number 0670
Washington, D.C. 20073 |
| FOR
CREDIT CARD ORDERS, PLEASE FAX FORM TO (703) 562-2296. |
| Visa:
____ M/C: ____ |
| Card
No: ___________________________
|
| Expiration
Date: _____________________
|
| Name
on Card: ______________________
|
| Signature:
__________________________ |
| HB31-001-9999-343104 |
PC
7062 |
