REQUEST FORM

Please accept my request for ____________ Pennsylvania Masonic Blazer(s),
size(s) ____________________ at $200 each, which includes S&H.
I have enclosed my check or money order. Please ship the blazer(s) to:

______________________________________________________________________
NAME

______________________________________________________________________
ADDRESS

______________________________________________________________________
CITY

______________________________________________________________________
STATE, ZIP CODE

______________________________________________________________________
PHONE

Sizes: Regular 36-52; Short 38-46; Long 38-50; Extra Long 40-48
(Any questions regarding sizing, call Mr. Ali Khatama at 1-800-251-232)

CREDIT CARD INFORMATION
If mailing this form with a check please leave this area blank.

______________________________________________________________________
Card Type (MasterCard, VISA, American Express)

______________________________________________________________________
Card Number

______________________________________________________________________
Expiration Date

______________________________________________________________________
Card Holders Signature

Print this form on your printer, complete and mail with your check or credit card information to:
The Masonic Library and Museum
Masonic Temple
One North Broad Street
Philadelphia, PA 19107-2520

or Fax to John H. Platt, Jr. at 215-988-1972

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