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  $6.00 each =  ______



                   TOTAL ENCLOSED      __________



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


MD-20 New York & Bermuda Lions Inc.
200 GATEWAY PARK DRIVE
BUILDING A
NORTH SYRACUSE, NEW YORK, 13212

Name    ____________________________________________________________

Address ______________________________________________________________________________

City/State _______________________________________   Zip  ________________________