Burke Order Form

Please fill out and mail this form with your payment information. You can figure your total cost at
http://www.cfww.org/campaigns/BURKE_index.asp

Name:__________________________________________________________________

Shipping Address__________________________________________________________

(No P.O. Boxes Please)________________________________________________________

________________________________________________________

Country ________________________________________________________

Number of Burke's ___________________________

Please mail this information to either of the provided sources below with your payment information.

Payment Methods:

1. Checks Payable to: Cystic Fibrosis Worldwide
Send payment and final order form to: Christine Noke, 210 Park Ave #267, Worcester MA 01609, USA

Please mail this completed form with payment to:

CFW
Christine Noke
210 Park Ave #267
Worcester MA 01609