[__________] @ 2.00 each = $ _________

Last Name: ________________________________ First Name: _________________

Mailing Address: _______________________________________________________

City/State/Zip:__________________________________________________________

Day Phone: (______) - _______________ Night Phone: (______) - _______________

E-Mail Address: ____________________________ Fax: (______) - _______________

Proceeds from the sale of this item will be used by TxCARE to further our Mission and Vision.

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