SPA Merchandise Order Form | Society for Pediatric Anesthesia

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GEAR:
Please indicate quantities you wish to purchase below

SPA History Book ($10.00)

Vineyard Vines Tie - Raspberry ($65.00)

Vineyard Vines Tie - Blue ($65.00)

Vineyard Vines Tie - Yellow ($65.00)

Vineyard Vines Bowtie - Raspberry ($45.00)

Vineyard Vines Bowtie - Blue ($45.00)

Vineyard Vines Bowtie - Green ($45.00)

Vineyard Vines Bowtie - Yellow ($45.00)

Vineyard Vines Bowtie - Orange ($45.00)

Vineyard Vines Pullover - Large ($85.00)

ITEM SOLD OUT

Vineyard Vines Pullover - Medium ($85.00)

Vineyard Vines Pullover - Small ($85.00)

Vineyard Vines Pullover - Extra Small ($85.00)

Pashmina ($40.00)

Umbrella ($40.00)

$250 Donation to the SPA Patient Safety Education Fund
Includes your choice of any ONE of the above items

Do not mark any of the items above in addition to your donation unless you intend on purchasing additional items, as this will add to your total.
If selecting this option, please indicate the item included with your donation from the following list:

CONTACT INFORMATION
First Name:
Last Name:
Degree: MD PhD Other (specify)

Email Address:

BILLING INFORMATION
Card Holder Name:
Billing Address:
City:
State/Province: (if applicable)
ZIP Code:
Country:
Card Number:
Security code:
Expiration Date:

SHIPPING INFORMATION
Check this box if shipping address is the same as billing address.
Mailing Address:
City:
State/Province: (if applicable)
ZIP Code:
Country: