Save The Palace T SHIRT Order Form Save The Palace 517 North Magnolia Elmwood, IL 61529 Simply print this off and begin filling out the form below: Shipping Information: Name _______________________________ Address _______________________________ _______________________________ City _______________________________ State _____ Postal Code ___________ Phone _______________________________ Email _______________________________ *Please provide either a phone # or an email address, so we can inform you when your order is ready for pickup or has been shipped. _______________________________________________________________________________________________________ Place an 'X' in the field for which size you would like. Place an 'X' in the field to indicate whether you would like to pickup locally or have the item shipped to your home. Item Small Med Large XLarge Qty Price Total _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ _____________________________ __ __ __ __ ___ x $15.00 = $_________ Shipping Options: Local Pickup ________ Priority Shipping 1 - 3 Shirts is $5.00 Priority Shipping 4 or more is $11.00 If using Priority Shipping, write $5.00 or $11.00 here: $ ________ Grand Total: $ ________ Make check or money order payable to: Save The Palace Theater Mail To: Save The Palace 517 North Magnolia Elmwood, IL 61529 Someone will contact you when your order will be either ready for pickup or when it will ship. Thank You!