Date:_____________ Name: _______________________________________________________

Street Address: __________________________________________________________________

City/State/Zip: ___________________________________________________________________

Telephone: __________________________Email Address _______________________________

TBAI 2011 Pins

$5.00 each

Qty ________

Total $_______U.S.

Please check one:

_____I will pick up my order at the TBAI 2011 on August 11 - 13, 2011 _____Mail my order (First class in US; Airmail Canada & Overseas) Mailed orders will be filled the week following TBAI.

We are unable to specify postage charges. You will be charged actual postage, packaging costs and $1.00 handling fee for your order.

Mail to:	TBAI
	4131 Rte 9
	Plattsburgh NY 12901
	USA

Check or credit card for orders to be picked up at Gala August 12. Make checks payable to TBAI.

Payment by credit card required for orders to be mailed.

Charge my Visa or MasterCard (circle one):

Credit Card # __________________________________________ Exp Date: _________________
CVV2 (3-digit # on back of card)_________

Name as it appears on the card: __________________________________________________

Signature of Cardholder ________________________________________ Date: ___________