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Commemorative Shirt ORDER FORM

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					                                   Commemorative Shirt
                                     ORDER FORM




To commemorate this year’s 25th Anniversary of Gallangowan, a Special Edition Shirt is available
for purchase. This shirt is 100% cotton, white long sleeve round neck with black event logo screen
printed on. Price $15.00 .

Orders and payment must be received by 17th November 2008 and will be available for pick up at
pre Meeting Scrutiny, Goodyear Autocare Sumner Park on 3rd December 2008.

NB: Competitors who place their entries prior to 17th November will receive two shirts included in
their entry fee. Entries received after this date is not guaranteed a shirt.


Please fill in the following details and send to:-
C
Post: C/- Sheridan Hetherman, 18 Shaun Place, Keperra, Qld 4054
Email : info@gallangowan.com.au                    Fax: 07 3846 0244

Name: ________________________________________________________________________

Address: _________________________________ Suburb: _____________________________

State: _____________               Post Code: ____________       Phone: _______________________

Email: _______________________________________________________________________
                           T-
Size:                                             SM M       L    XL 2XL 3XL
                      shirt Size   Unisex Adult
                                                  (10) (12) (14) (16) (18) (20)



Payment Method:          Cheque            Visa       Master Card            Direct Deposit
Note: Credit Card will incur a 3% fee.
Direct Deposit: BSB 084391 Account – 50845 2534. Please attach receipt. Ref SH (Your Name)


Credit Card Payment

CARD NUMBER: __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __           EXPIRY DATE: __ __ / __ __


Signature ____________________________________           Date ___________________________

				
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Description: Commemorative Shirt ORDER FORM