AU Display Request Form 

Club Name: _________________________ accepts responsibility for returning
the display to the regional coordinator, and to be returned, "postage paid". 
The preferred method of shipping is UPS Ground. 

Club President signature: _____________________________________ 

Club Secretary signature: _____________________________________ 

Address: ____________________ State, City, Zip __________________ 

Phone: ______________________ Email ________________________ 

Date/s you are requesting to utilize the AU Display __________________ 

At what type function is the Display to be used _____________________ 

I have enclosed $_____ for shipping and insurance as requested. 

Signature: _________________________