ACA Mail Order Form

Name:

Membership #:

Address:

Phone: ( )

City: | State:

Zip:

Please Note: We cannot ship to P.O. Boxes

e-mail:

Item Number

Description
(Size, Color, Design)

Quantity

Price

Total

Use this form when ordering your Personalized Business Needs	Shipping & Handling
Item _______________________________ Name ______________________________ Business Name ______________________ Phone Number_______________________ Address ___________________________ ___________________________ Other ___________________________ ___________________________ Graphic Choice ______________________ Color Choice ________________________ Style Choice ________________________	$0 -$24.99 $25.00 - $49.99 $50.00 - $74.99 $75.00 and Over	$4.95 $5.95 $6.95 $7.95

Sub-total for
Business Items

MN Residents add
6.5% Sales Tax

Subtotal for Shirt
Orders (non-taxed)

Shipping &
Handling

Total

Method of Payment (check one): [ ] CHECK [ ] MONEY ORDER [ ] CASHIERS CHECK [ ] VISA [ ] MASTER CARD Card #: _________________________________ Exp. Date: _______	Adults & Childrens Alliance 2885 Country Drive suite 165 Saint Paul, MN 55117-2621	Local (651) 481-9320 Toll free 1-800-433-8108 Fax (651) 481-4919 Toll free fax 1-800-377-6685
Signature:		E-mail: childcare@acainc.org Web Site: www.acainc.org