Gup Certificate Order Form

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					Gup Certificate Order Form
Date:___________
School Name & Mailing Address: Club Name_________________________________________USAT Club#___________ Address__________________________________________________________________ City_________________________________State________________Zip_____________ Phone #:______________ Fax #:______________Email:__________________________ Instructor Name:______________________________________ Instructor Signature:__________________________________

Color Yellow Green Blue Red

Amount _______ _______ _______ _______

Total amount ordered _______ Total amount enclosed:$_________ Orders of 100 or more = $2.00 each Orders under 100 = $3.00 each Cashier’s Check____ Money Order____ Visa____Discover____ Mastercard____American Express____ Credit Card Number:_________________________________________ Expiration Date: _______________________Security Code:_________ Card Holder:______________________________________________
(Printed Name on Card)

Card Holder’s Signature:_______________________________________

Please mail or fax requests to: USA Taekwondo 1 Olympic Plaza, Suite 104-C Colorado Springs, CO 80909

Phone: Fax: Email:

719 866 3632 719 866 4642 adam.brown@usa-taekwondo.us