Preservation Alliance of La Crosse - Medallions Order Form

 Ea.    Qty.       Total          Description

$16 x ____ = $______ Holway House (1991) - SOLD OUT
$16 x ____ = $______ Old Court House (1992)
$16 x ____ = $______ Main Hall (1993)
$16 x ____ = $______ Mons Anderson House (1994)
$16 x ____ = $______ Christ Episcopal Church (1994)
$16 x ____ = $______ Pettibone Pavilion (1995)
$16 x ____ = $______ #4000 Locomotive (1996)
$16 x ____ = $______ St. James Catholic Church (1997)
$16 x ____ = $______ St. Rose Convent (1998)
$16 x ____ = $______ Cass Street Bridge (1999)
$16 x ____ = $______ First Evangelical Lutheran Church (2000)
$16 x ____ = $______ The Ott House (2001)
$16 x ____ = $______ Pettibone Beach House (2002)
$16 x ____ = $______ The LaCrosse Players (2003)
$16 x ____ = $______ The War Eagle (2004)
$16 x ____ = $______ The McGilvray Bridges (2005)
$16 x ____ = $______ Gambrinus (2006)
$16 x ____ = $______ The Pump House (2007)
_____________________________________
Total Order      $________         Shipping charges (within the U.S.):
Add Shipping  $________         1-5 medallions.... $1 each; 6-20 medallions... $6 total
Grand Total     $________         (21 or more, rush delivery, etc... call for quote)

 
Payment Method (check one):
_____ A check payable to PAL in the amount _________is enclosed
_____ Please charge my order to the following account:
 
Visa/MasterCard #: ______________________________________ Exp. Date: _____________
 
Authorized Signature: ____________________________________________________

Please ship the order to me at this address:
 
_____________________________________________________________________
Name
 
_____________________________________________________________________
Address
 
_____________________________________________________________________
City, State, Zip
 
(________)_____________________
Phone
 
 
Send this page with your payment to:
 
        Preservation Alliance of La Crosse
        119 King Street
        La Crosse, WI  54601

 Ea.    Qty.       Total          Description

$16 x ____ = $______ Holway House (1991) - SOLD OUT
$16 x ____ = $______ Old Court House (1992)
$16 x ____ = $______ Main Hall (1993)
$16 x ____ = $______ Mons Anderson House (1994)
$16 x ____ = $______ Christ Episcopal Church (1994)
$16 x ____ = $______ Pettibone Pavilion (1995)
$16 x ____ = $______ #4000 Locomotive (1996)
$16 x ____ = $______ St. James Catholic Church (1997)
$16 x ____ = $______ St. Rose Convent (1998)
$16 x ____ = $______ Cass Street Bridge (1999)
$16 x ____ = $______ First Evangelical Lutheran Church (2000)
$16 x ____ = $______ The Ott House (2001)
$16 x ____ = $______ Pettibone Beach House (2002)
$16 x ____ = $______ The LaCrosse Players (2003)
$16 x ____ = $______ The War Eagle (2004)
$16 x ____ = $______ The McGilvray Bridges (2005)
$16 x ____ = $______ Gambrinus (2006)
$16 x ____ = $______ The Pump House (2007)
_____________________________________
Total Order      $________         Shipping charges (within the U.S.):
Add Shipping  $________         1-5 medallions.... $1 each; 6-20 medallions... $6 total
Grand Total     $________         (21 or more, rush delivery, etc... call for quote)

 
Thank you for your order!