Print Form and Mail to:
St. Mary Foundation — Byers Choice Ltd. Figurine
One Summit Square, Suite 300
1717 Langhorne-Newtown Road
Langhorne, PA 19047

ORDER FORM:
______Girl – Byers Choice Ltd. St. Mary Figurine(s)
______ Boy – Byers Choice Ltd. St. Mary Figurine(s)
at $87.95 each (includes $12.95 S&H)
Your tax deductible amount is $43.00 per figurine.

Please make check payable to:

St. Mary Medical Center Foundation
or enter your credit card information below:

Name _________________________________________________

Address ________________________________________________

City ___________________________________________________

State _______ Zip ______________ Phone ____________________

Payment method: ❑ Visa ❑ Mastercard ❑ AmEx

Card No. _______________________________________________

Exp. Date _________________ Security Code __________________