Rotary Membership Card On-Line Order Form

Imprinted Plastic Membership Card Order Form

INFORMATION REQUIRED BY ROTARY FOR FRONT OF CARDS

Rotary Club Name:

Certified By
(Club Secretary's Name):

Valid Until
Date:

	/		/
Mo		Day		Year

District
Number:

Club
Number:

ORDER INFORMATION

Membership Card Format	Quantity	Unit Price	Total

Imprinted Cards		$1.75
DuraHyde Compu-Attaché		$39.00
Centennial Luggage Tags (4/pkg)		$10.00/4pk

		Sub Total
	7% Sales Tax (Illinois residents only)
	Shipping charges will be added
		ORDER TOTAL

SHIP TO ADDRESS

Street Address:

City, State, Zip Code:		,
Province (outside USA):
Country:
Phone Number:
Fax Number:
E-mail Address for Order Confirmation:

CREDIT CARD INFORMATION:

Type of Card:

Account Number:

Expiration Date:

	/
Mo		Year

Name as it Appears on Card:

Card Billing Street Address:

City, State, Zip Code:

Province (outside USA):

Country:

MINIMUM ORDER IS $10.00 US

MEMBERS TO RECEIVE IMPRINTED PLASTIC CARDS
Note: Your must follow the directions on the web page that appears
after you have clicked buttons (1) and (2) below.

(Allow approximately 2 weeks for delivery)

Parker Systems, Inc.
20989 Middleton Drive
Lake Zurich, Illinois 60047-8698 USA

(800) 253-5100 - (847) 726-8600 - Fax (847) 726-8610

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