IMAGE: Brinton Family Coat of Arms

Brinton Association of America

Plate Order Form
Ship Plate(s) To:
Name:
Address:
,     -



Plate Name                Quantity Price Amount
Brinton 1704 House   x $75.00 $

Pennsylvania residents, please add PA Sales Tax (6%) $
Total Plates Ordered   x $8.00 each (Shipping Costs) $

TOTAL AMOUNT DUE: $


Payment: Check or VISA MasterCard Exp. Date /


Name on Card (print) 

Authorization (sign)   
Purchaser's Phone Number:  () -

$25 per plate is tax deductible.

Form instructions

  1. Print and fill out this Plate Order Form.
  2. Make a check payable to "Brinton Association of America, Inc." for the total amount due;
    or
    Provide the credit card information requested on the form, including card number and signature.
  3. Mail payment and completed order form to:

    		The Brinton Association of America;  
    21 Oakland Rd.; West Chester, PA 19382.
Official web site of the Brinton Association of America, Inc.
http://www.brintonfamily.org