Arizona Silent Service Memorial (ASSM) Challenge Coin Order Form

Please print this page, fill-out form and mail to:

ASSM Foundation

Attn: Tim Moore

18741 N. 92nd Drive

Peoria, AZ 85382-3646

ASSM CHALLENGE COIN ORDER FORM

$25.00 each

(Free Shipping to U.S. Addresses)

Contact Tim Moore for bulk purchases and/or Foreign Shipping Costs

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Quantity: ___ x $25.00 ea. Total Order: $____________

Please Ship my order to the following address:

Name:
Address:
City:
State
Zip Code:
Email:
Phone:

 

Make Checks payable to: Arizona Silent Service Memorial or ASSM.

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To use a Credit Card to place your order and mail it in, please fill in the information

below.

Name on Card:
Credit Card Type:
Credit Card Number:
Expiration Month:
Expiration Year:
CVV Number:
If Billing Address is different than Shipping Address, please provide the information below:
Name on Card:
Address:
City:
State:
Zip Code:

To order your Challenge Coin(s) online click this link.  You do not have to be a PayPal member. 

ASSM uses PayPal to process orders and your Credit Card can be used without having to be a PayPal Member.