2008 Performance Fund Form

First Name

Last Name

Street Address

City            State AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NB NC NE NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY         Zip

Country United States Canada Australia Japan New Zealand Sweden Africa

Email Address

Phone Number

I would like to:

Make a monetary donation     Amount

Purchase Print ~ $55.00

Purchase T-Shirt ~ $35.00            Purchase T-Shirt AND Print ~ $65.00

T-shirt size:     S     M     L     XL     2XL   

3XL    Note: for size 3XL add an additional $5.00 to your order

Total Amount enclosed

   ******  Mail your payment so that it is received by April 4, 2008! *********

Print out form and mail with payment to:

Meg Ispas Hennessey
P.O. Box 257
Marengo, IL 60152-0257

*** Note: All t-shirts and prints will be mailed! ***