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PRINT THIS FORM OUT AND COMPLETE
TO PAY BY CHECK Please Print Clearly RETURN TO : (Make checks payable to Joseph Fagan) JOSEPH FAGAN - PO BOX 306 - NETCONG, NJ 07857 YOUR NAME ____________________________________________ ADDRESS ______________________________________________ STATE _________ ZIP CODE _________ Centennial Celebration CD $ 12.95 SHIPPING AND HANDLING $ 2.25NJ RESIDENTS PLEASE ADD 7% SALES TAX $ _______ TOTAL ENCLOSED $ _______ |