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Name: ___________________________________________________________

Address: _________________________________________________________

City: ____________________ State: __________ Zip: __________

Telephone number to contact if I have questions: ( ) _____________________

Event Name Category Photo Number 11x14 8x10 5x7 4x6 Wallets Total

___________ __________ ____________ ____ ____ ____ ____ ____ ____

Shipping Cost is $4.00 per entire order (use multiple sheets if you need) : 4.00

Total enclosed: ______

Mail check to:

Andrew Rubenstein, MD

35022 Meadow Lane Court

Farmington Hills, MI 48335

Phone: (248) 615-9183

Medical Office phone: (734) 453-5360

Send photography related questions to: PlymouthPictures@AOL.COM

Thanks!

Andy Rubenstein