LIMITED EDITION CANVAS ORDER FORM

Dear Supporter,
Before you fill-out the form, Please, make sure you selected 3 Canvas available numbers:
Limited Edition Canvas Reservation Form

Subject:

Canvas Number Requested

1st choice:

2nd choice:

3rd choice:

Name:

Company:

Address:

City:

State:

ZIP:

Phone:

Fax:

Cell:

E-Mail:

Date:

Can we post your name or your company name as contributors on our website	YES	NO

A specific canvas number can only be reserved with payment.

Do you wish to join the Flag of Honor Fund sponsorship program that allows you to donate a Family Canvas to the victim’s family of your choosing in your name and also to receive a framed Limited Edition Canvas for yourself

YES	NO

Please send the "Flag of Honor" Canvas as a gift to the following victim's family:

All information provided is strictly confidential.

OFFICE USE ONLY

Canvas Number Provided:

Order Date:

Shipment date:

Method of Payment:

Payment Date:

Additional Donation:

Review Your Entries

Thank you for your support of the Flag of Honor Fund. Flag of Honor Fund is a 501c3 charitable organization.
Your contribution is tax deductible as provided by law. Federal Tax ID 55-0840201.

741 Riversville Road
Greenwich, CT 06831
Tel/Fax: 203-863-9161
E-mail: flagofhonorfund@aol.com