Payment for `Teddy Bears for Vets

MWV Teddy Bear order FORM Page 1

Current Office/ Title *

Lodge Name & Number

Address *

City *

Address2

State *

Zip *

Phone *

Email *

Ship Bears *

Please Ship the Bear to my address:

Please Take the Bear to a VA Hospital:

Total # of Bears (required) *

Total Amount

$

Payment method

Credit Card

Billing Zipcode*

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*