SIPKyshoppe_order



	To order by check or money order, please copy the Donation/Order form below, print it out and fill it out completely and legibly. Then send it along with your donation to: The Southern Independence Party of Kentucky 318 Hunter Dr. Murray, Kentucky 42071

		Donation/Order form NAME________________________________ ADDRESS____________________________ CITY_________________________ STATE___________________ YANKEE OCCUPATION CODE (ZIP CODE)___________________ PHONE NUMBER __(________)____________________________ EMAIL ADDRESS_____________________@_________________ BOTTLES OF COLOGNE: ($20.00 each) SECESSION (POLO type) ..................................................__________ SOUTHERN GENTLEMAN (GREY FLANNEL type)........__________ TOTAL NUMBER OF BOTTLES........................................__________ SIP Ky wall clock $26.00 times number ordered = ....._________ Ky. Secession document $15.00 times number ordered =...._________ AMOUNT ENCLOSED..........................................................__________ CHECK OR MONEY ORDER NUMBER......___________________________________________