To place your order, please fill out the order form below:

Item Number                                       Quantity                          

A. Signed and Numbered ...  $25.00         (Sold Out of Signed and Numbered)            

B. Signed Only ... $20.00                                     

C. Note Cards ... $6.50                                        

D. Framed Print ... $160.00                                 

Total Purchases             

Shipping and Handling   

SubTotal                       

Tax @ 6% for KY or IN  

Total Due                      

Express Shipping will be at current market cost and will be billed to a credit card after shipment.
 

Name:                          

Street Address:             

Address (line 2):           

City:                             

State:                           

Postal-Code:                 

Country:                       

Telephone Number:      

Fax:                             

Email:                          

Payment Information

Type of Credit Card:      Visa Mastercard

Name on Credit Card:   

Credit Card Number:     

Expiration Date (e.g., 06/09):

Charge Amount Authorized: US $

        Shipping and Handling (this amount will be added to your amount authorized)

        $  5.01 to $15.00 = $4.50                      $75.01 to $90.00 = $12.95

        $15.01 to $30.00 = $6.50                    $90.01 to $200.00 = $14.95

        $30.01 to $60.00 = $9.95                  $200.01 to $499.99 = $26.00

      $60.01 to $75.00 = $10.65                         $500.00 and up = $35.00

If the billing address for your credit card is different than your shipping address, please supply that in the box below:

Comments or Notes:

If you do not wish to use a credit card, please mail your payment with order details to:

Kentucky Nurses Association

P.O. Box 2616

Louisville, KY 40201-2616