| FAX |
| To: |
Freedom Works! Inc. - 801-426-6646 (Your credit card statement will show Great Western Mint) |
| Re: |
Silver Presidential Medallions |
| Billing Name: |
(SAME AS ON CREDIT CARD) |
| Billing Address: |
(SAME AS ON CREDIT CARD) |
| Shipping Name & Address: |
|
| Credit Card Type: |
|
| Credit Card Number: |
|
| Credit Card Expires: |
/
|
| Authorized Amount: | $24.95 plus $6.95 for shipping and handling |