Make check payable to MOEMS

ENCLOSED is Check #_____or Purchase Order # ______
Or Credit Card: q MasterCard q VISA q Discover q American Express
 # _____ _____ _____ _____ Expires ____ Security Codeˆ ___
Item ADULT Size Quantity Domestic Unit Price Foreign Unit Price TOTAL PRICE
T-SHIRT Small  
@ $10.00
@ $12.00
 $
T-SHIRT Medium  
@ $10.00
@ $12.00
 $
T-SHIRT Large  
@ $10.00
@ $12.00
 $
T-SHIRT X-Large  
@ $10.00
@ $12.00
 $
Cap    
@ $6.00
@ $8.00
 $
Pennant    
@ $1.50
@ $2.00
 $
        TOTAL $
  Mail to:   
  Name______________________________ School_______________________________
  School Address ______________________ City/State/ZIP _________________________
  Country ____________________________  
  email ______________________________ Telephone ____________________________
  Billing Address, ____________________________
   if different from Mailing Address:  ____________________________
    ____________________________

Complete this form and mail to:

Or fax the form to:

Or, during business hours,

 

 

 phone a credit card order to:

Math Olympiads

 

 

ATTN: Publications Department

2154 Bellmore Ave

(516)785-6640

(866)781-2411

Bellmore, NY 11710-5645