Online Store Order Form

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By Telephone: (530) 272-3265, 9:00am - 4:00pm, Reservations, Credit Card Payment.
By Fax: (530) 272-5212, 24-Hours, Fax this form, Credit Card only 
By Mail: Mail this form with payment to: 
Health & Safety Dept., American Red Cross, P.O. Box 250, Grass Valley, CA 95945
In Person: 144 Hughes Road, Grass Valley, Suite G , 9:00am - 4:00pm


Name___________________________________________________________________________________ 

Home Phone:________________________________ Work Phone: _________________________________

Address_________________________________________________________________________________

City, State, Zip___________________________________________________________________________

Course Name:___________________________________________________________________________

Item:___________________________________Quantitiy_____Price Each: $ _______Total: $ _________

Item:___________________________________Quantitiy_____Price Each: $ _______Total: $ _________

Item:___________________________________Quantitiy_____Price Each: $ _______Total: $ _________

Item:___________________________________Quantitiy_____Price Each: $ _______Total: $ _________



Shipping: $2.00 per item: ______________________________Quantity: ___________Total: $ _________



__ Total Amount Enclosed..................................................................................Amount $ _________


Payment (Must be received before class date. Confirmation will be made within 48 hours)

Paid By: Check____ VISA____ MasterCard____ 

Card No.____________________________________________________ Exp Date:__________________

Cardholder's Name_________________________Signature_________________________Date_________


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