The University of Arizona

History of Pharmacy Museum Gift Shop Order Form

To better serve you, please print this form and make sure that all required fields are properly filled out. Required fields are those marked with an "*".

*Item		*Quantity	Price	*Total
Flores Corner, 1930 print (measures 30" x 24")			$100	$
Territorial Pharmacist print (measures 36" x 21")			$25	$
Dillinger at the Owl Drug print (measures 24" x 36")			$25	$
Product labels from Arizona pharmacies			$20	$
25 "Flores Corner" note cards with envelopes		Sold out	$10	$  Sold out
25 "Territorial Pharmacist" note cards with envelopes			$10	$
25 "Owl Drug Store" note cards with envelopes		Sold out	$10	$  Sold out
			Total Purchase	$
Please note: Your payment for Museum Gift Shop merchandise other than the "Flores Corner, 1930," print are NOT considered a tax-deductible contribution to The University of Arizona Foundation. Thank you!
Buyer Information
*First and Last Name:
*Address:
*City, State, Zip:
*Telephone number:
*Amount Paid:	$
*Method of Payment:	Visa MasterCard Check (Checks made payable to the UA Foundation.)
Credit card number:
Expiration date:
Signature:
Shipping Information, if different from buyer information above.
First and Last Name:
Address:
City, State, Zip:
Telephone number:

Mail order form to:

UA History of Pharmacy Museum

P.O. Box 210202

Tucson, AZ 85721-0202

Or, fax order form to:

(520) 626-4063