Membership Application / Order Form

Print out this page, fill it in and mail with your check or money order to:

LABELIT POISON™
1437 Grand Drive
Ft. Lauderdale, Florida 33312

Name      ____________________________________  Phone  _______________________________

Location  ____________________________________  Fax    _______________________________

          ____________________________________  E-mail _______________________________
		  
          ____________________________________  Other  _______________________________

Select one:  ___Tote Bag  or  ___Book Bag  or ___T-shirt  S  M  L  XL  XXL (Add $2)

Membership:  ___Single ($50)  ___Family ($50 + $3 for each additional membership card)
   
Additional T-shirts may be        Quantity: ______  Size: S  M  L  XL  XXL (Add $2)
 purchased @ $16.00 each.
                                  Quantity: ______  Size: S  M  L  XL  XXL (Add $2)
												  
                                  Quantity: ______  Size: S  M  L  XL  XXL (Add $2)
													  
                                  Quantity: ______  Size: S  M  L  XL  XXL (Add $2)
													  
                                  Quantity: ______  Size: S  M  L  XL  XXL (Add $2)
									
									
                                               TOTAL AMOUNT ENCLOSED $ ______________
									
									
													  
We are interested in your interactive program for our school/organization.


Name    _________________________  School _________________________________ Age _____


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