p s g e t p a a
 

ORDER FORM

          The Paget Foundation
Awareness Wristband

 
Another way to support the Paget Foundation and raise awareness.

The new blue foundation wristband is imprinted with the slogan SUPPORT PAGETíS - SUPPORT BONES and the address of the
Paget Foundation website.

Please complete the form below and then click the SUBMIT button.

  Note: You may need to use the scrollbar to complete this form.

(* indicates required field.)


Amount of wristbands I would like to order:
$ 3.50 - 1 (one) wristband $ 15.00 - 10 (ten) wristbands
   
Please check which credit card you would like to use:

Visa MasterCard AMEX

Card No.
Expiration Date (MM/YY)
Name on Card

Please fill in contact information below:

* First Name:  
* Last Name:  
Title:  
* Address:  
 
* City:  
* State/Province:        * Zip/Postal:
* Contact E-mail:  
Contact Phone:
Contact Fax:  
Comment:
Verify Security Code:  E 2 Q W

You may also fax this form or print and mail with payment to:
(please make checks payable to: THE PAGET FOUNDATION)

  The Paget Foundation
120 Wall Street, Suite 1602
New York, NY 10005-4001
Tel: 212-509-5335
Fax: 212-509-8492
E-mail: Pagetsym@aol.com