PATCH ORDER FORM

PLEASE SEND ORDER FORM TO:	Blinded Veterans Association 
477 H. St., NW 
Washington,, DC 20001

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NAME:__					
ADDRESS: 					
CITY, STATE, ZIP					
PHONE: (       ).					

STATE:

Type of Patch	Price	Quantity	
Four Inch (4")	$4.00		
Two Inch (2")	$2.75		
TOTAL	$		
Please make checks payable to Blinded Veterans Association. If you would like to charge your order please fill out the form on the back of this page.