MWC Member “SHIP TO” Name _______________________________________________________________________________________________
Address ________________________________________________________________________________________
MWC Mbr #____________________________________
Phone_______________________________
City __________________________________
State __________________________Zip _______________________
Date of MWC Renewal _________________
Date of Ranger/Mercury Pkg Purchase___________________________
Personalization
_______________________________________________________________________________________________
JACKET ONLY (Please include
$4.00 for first five (5) letters, and $.50 for each additional letter)
Charge for personalization
__________________
Please charge to: Mastercard Discover
Visa
State/Local Tax (if required)
__________________
Card # __________________________________________
Total Amount Enclosed
__________________
Expiration Date ____________________________________
Signature _______________________________________________________________________________________
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