SPA Merchandise Order Form

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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


Degree:
MD
PhD


BILLING INFORMATION








SHIPPING INFORMATION
 Check this box if shipping address is the same as billing address.





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2209 Dickens Road, Richmond, VA 23230-2005 · Phone: 804-282-9780 · Fax: 804-282-0090 · spa@societyhq.com

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