Air Force Pride badge - Girl Scout Council - Colonial Coast

Girl Scout Council of Colonial Coast Patch Order FormMail this form with total payment to:Girl Scout Council of Colonial CoastC/O Retail Manager912 Cedar RoadChesapeake, VA 23322Fax this form to: (757) 547-1872E-mail this form to: lindah@gsccc.orgName ___________________________________Troop # _______ Age Level (Circle One) DS BR JR CD SR ABStreet Address _____________________________________ City ______________________ State _______ Zip ________Phone ____________________________E-mail address ______________________________Patch/Award name ________________________________________Patch/Award name ________________________________________Patch/Award name ________________________________________Patch/Award name ________________________________________Patch/Award name ________________________________________Quantity ________Quantity ________Quantity ________Quantity ________Quantity ________Postage & Handling:Under $5 = $1$5.01 - $10 = $2.95$10.01 - $25 = $3.95$25.01 - $35 = $4.95$35.01 - $45 = $5.95$45.01 - $35 = $6.95$55.01 - $45 = $7.95$65.01 - $45 = $8.95$75.01 - $35 = $9.95$85.01 - $45 = $10.95$100 - over = $15Total # of Council or Explore Patches _________ x $2.25 = $ __________Total # of Council’s Own Awards _________ x $1.50 = $ __________Postage & Handling* (see chart)TOTAL AMOUNT ENCLOSED= $ __________= $ ____________ Cash__ Check __ Credit Card ( Make checks payable to GSCCC)We accept Discover, Mastercard and VisaAmount to be charged: $_______________Card Number:__________ -- ___________ -- __________ -- ________Expiration Date:____________ (Mo/Yr)Print name as it appears on card _______________________ Authorized Signature:_______________________________If paying by Check, I agree that my account will be debited electronically for the face amount, return check fee and returndeposit item fee if returned unpaid.ADULT SIGNATURE: _______________________________________________DATE________________