Date:

Name:

Address:

City: State: Zip:

Phone: Quantity: x $15 = (total) $

Please fill out and Print.
Make the check payable to: P.C.B.C. and mail to:
Grovene Anderson (Diamond Book)
2711 S. Bateson Ave.,
Rowland Heights, Ca., 91748
(626) 964-1301

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