BILLING INFORMATION SHIPPING INFORMATION (If different from Billing) Name  * required Name Address  * required Address City, State, Zip, Country  * required City, State, Zip, Country Day & Evening Phone Numbers  * required Day & Evening Phone Numbers Email  * required Email REGIONAL and STATE MEDALS RIBBON COLORS Blue # Red # White # Total # Medals Total $ Amount Regional Medal (1 3/4 ") (w/30" Ribbon) $1.50 State Medal (2") (w/30" Ribbon) $1.55 OTHER MEDALS   Number Ordered Cost per Medal Total $ Amount DaVinci Medal(2")              BLACK center background (w/30" Black Ribbon) $1.88 Renaissance Award Medal (1 7/8") (w/30" Purple Ribbon)   $1.44 SPIRIT Award Medal (1 7/8") (w/30" Red Ribbon)   $1.44 Rising Stars Medals (1 5/8") (w/30" Red Ribbon) $1.20 CHALLENGE PINS Size 1 1/2" Number Ordered Cost Per Pin Total $ Amount Challenge A Direct Diposit $0.65 Challenge B DI-Bot $0.65 Challenge C You're Gonna Flip! $0.65 Challenge D DO or DI $0.65 Challenge E Breaking DI News $0.65 Rising Stars Weighty News $0.65 Project Outreach Band Together $0.65 OTHER PINS Number Ordered Cost Per Pin Total $ Amount DIAlumni Pins $0.65 Dog Tags $1.50 Instant Challenge $0.65 Appraiser Pin $0.65 Parent Pin $0.65 Team Manager Pin $0.65 IDODI Pin   $1.14   Total Order Affilliate Affiliate Name State Competition Date Regional Competition Date(s) 2009-2010 LASTING IMPRESSIONS

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