Total Amount Due:___________

Please clearly print inscription below for each plaque purchased :

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Make Checks out to Triangle Recovery Club and mail check and your form to Po Box 106 Woodbine, Md 21797 and put                                                                    Memorial Plaques in Memo or go below and use credit card or pay pal                                                                        ( There is a spot to put your name you want on plaque in notes section)