E-mail Directory Listing Form

		Please print this form & mail it in with your E-mail Directory Order

	$12.00 - 3 year listing

Name:__________________________________

Club Name: ____________________________

Club No: _________________ State: __________

E-mail: _________________________________

Amount Paid: _____________________________


	Please type or print clearly: Make Checks Payable to: Supreme Emblem Club % Judy Lyon, Web Master 2515 Mt Vista Centralia, WA 98531