Pin Order Form

To order pins, print this form and send it to us, along with your payment.

Academy for Cancer Wellness

6616 E Carondelet

Tucson, AZ 85710

Tel: (520) 722-4581 Fax: (520) 722-4582

E-mail: AFChang@cancerhealth.org

Name________________________________________________________________

Address______________________________________________________________

City_______________________________State__________Zip__________________

Phone______________________(Day)______________________________(Evenings)

Yes, I would like to purchase pins from the Academy of Cancer Wellness.

Please find below my order of pins at $5 each:

(for orders of 10 or more please contact us directly).

• The Champion pin             Qty________ @ $5ea   ___________

• The Caregiver pin              Qty________ @ $5ea  ___________

• The Family & Friends pin  Qty________ @ $5ea   ___________

                                                                  Total    $______________

Make checks payable to the Academy for Cancer Wellness. (ACW)

VISA/MC _____________________________________

Exp.________________ Amount $._________________

_____________________________________________

Signature

Home Page | Mission Statement | The Pins | Brief History | Donations & Volunteers