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Name: ___________________________________________________________

Address: _________________________________________________________

City:  ____________________             State:    __________        Zip:   __________

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

 

Event Name          Category        Photo Number    11x14 ($10)    8x10 ($7)     5x7 ($5)      4x6 ($3)     Wallets ($5)     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) 453-9500

Send photography related questions to: PlymouthPictures@AOL.COM

Thanks!
Andy Rubenstein