Canada Club! Order Placemats Form
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Contact Information
Title
*
:
Title
Mr.
Mrs.
Ms.
Miss.
Dr.
Prof.
First name
*
:
Last name
*
:
CSA Membership Number
*
:
Canadian Contact Telephone Number
*
:
US Contact Telephone Number
*
:
Contact E-mail Address
*
:
Canada Club! Information
Name of Canada Club! Event
*
:
Location of Event (i.e. Park Name)
*
:
Date of Event
*
:
Time of Event
*
:
AM / PM
AM
PM
Description of Event:
Mailing Instructions
Number of Placemats Required
*
:
Requested Delivery Date
*
:
Mailing Address for Placemats
Care of
*
:
Street Number
*
:
Street Name
*
:
Other:
City
*
:
State / Province
*
:
Zip / Postal Code
*
:
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