Louisiana Czech Museum
 
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2003 Louisiana Czech Museum Raffle Calendar Order Form:
 Please Print Form and Mail to the Louisiana Czech Museum
 
 NAME:                                                                                        
 
 ADDRESS:                                                                                        
 
                                                                                       
 
 CITY:                                                                                        
 
 STATE:                                            
 
 ZIP:                                            
 
 PHONE (HOME):                                                                                        
 
 PHONE (WORK):                                                                                        
 
 EMAIL:                                                                                        
 
 This Calendar has been purchased as a gift by:                                                                 
 
 I would like to donate my winnings to the Louisiana Czech Museum                                                               
 (Signature & Date Required for Authorization)
 
 I would like to donate in Memory of                                                                 
 
                                                                                    
 (Signature & Date Required for Authorization)

Print and Mail Form, with the $22 Contribution ($20 for Calendar and $2 for Shipping) to the:


Louisiana Czech Museum
P.O. Box 475
Libuse, LA 71348


Registered Non-Profit in the state of Louisiana
Make check payable to: Louisiana Czech Museum

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