Official New York State and Bermuda Tie and Patch 
ORDER FORM
  




New York State and Bermuda official tie                 _____  at  $20.00 each =  ______

New York State and Bermuda official patch          _____  at  $5.00 each =  ______



                                       TOTAL ENCLOSED      __________



Please send payment ( CHECK OR MONEY ORDER, no credit cards) to:


NYS & Bermuda Lions Clubs
526 Oak Street,
Syracuse, NY 13203 

Name        ____________________________________________________________

Address ______________________________________________________________________________

City/State _______________________________________   Zip  ________________________