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_____________________@_________________
NUMBER OF BOTTLES OF:
SECESSION (POLO type) ...................................................__________
SOUTHERN GENTLEMAN (GREY FLANNEL type)........__________
TOTAL NUMBER OF BOTTLES........................................__________
MULTIPLY TOTAL NUMBER OF BOTTLES TIMES $15.00
TO EQUAL MINIMUM DONATION
AMOUNT ENCLOSED..........................................................__________
CHECK OR MONEY ORDER NUMBER......___________________________________________
