Lone Star Chapter of NATAS

Item	Price	Select	Quantity
Production Certificate	$25.00		Only one item per order
Nomination Plaque	$100.00		Only one item per order
Production Plaque	$125.00		Only one item per order
Replacement Statue	$250.00		Only one item per order
Duplicate Statue	$300.00		Only one item per order

All items ordered above will contain the following information
for Role/Credit, Entry Title, Category and Year.
One one item per order.

Name, Role/Credit: *

Entry Title: *

Category: *

Year of Nomination/Award: *

Station/Company: *

First Name: *

Last Name: *

Delivery Street Address: *

Delivery City: *

Delivery State: *

Delivery Zip Code: *

Phone: *

(enter as xxx-xxx-xxxx)

E-Mail: *

Payment Method: *

Billing Information for Online Credit Card Payments

(All required for Payment Method of Credit Card)

Credit Card Type:

Credit Card Number:

(All numbers, no spaces or hyphens)

Expiration Date:

Credit Card Verification Number:

3 digit number on the back of the card in the signature line

Billing Information for Online Electronic Check

(All required for Payment Method of E-Check)

Bank Routing Number (ABA Code):

Bank Account Number:

Bank Account Type:

Bank Name:

Customer Name on the Bank Account:

General Billing Information

(Enter street address and zip at a minimum and other values if different than above. Used for credit card/checking account verification.)

Billing First Name:

Billing Last Name:

Billing Company:

Billing Address: *

Billing City:

Billing State:

Billing Zip Code: *

Billing Phone:

(enter as xxx-xxx-xxxx)

Billing E-Mail:

Additional Information:

* Fields marked with an asterisk are required.