Honorary Service Award (Hsa) Order Form printable pdf download

2327 L Street, Sacramento, CA 95816-5014

916.440.1985 • FAX 916.440.1986 • •

HONORARY SERVICE AWARD (HSA) ORDER FORM

All monies raised with the sale of HSAs fund the California State PTA Scholarship and Grant Program.

Presented By

__________________________________________________________ PTA/PTSA Unit # _______________

Name of PTA unit, council or district presenting HSA Award

Please Print Clearly

PTA Council _______________________________________________________________ District PTA # _______________

Ship To – Contact Person

: ____________________________________________________________________________

Street Address _________________________________________________________________________________________

City _____________________________________________________________________________ Zip ________________

Email ___________________________________________________ Telephone (________) _________________________

PRICES

AWARDS – See Toolkit for Descriptions

HSA ORDER TIPS

Certificate Only

Cert. + Pin

VSP

Very Special Person Award

$15

$23

• Allow up to 2 weeks for delivery.

• Awards are not mailed to recipients.

HSA

Honorary Service Award

$30

$35

• See your completed certificate online.

CSA

Continuing Service Award

$30

$35

• Order online at

GOSA Golden Oak Service Award

$60

$80

• For rush orders, a $10 fee is added plus

applicable shipping costs.

OTA

Outstanding Teacher Award

$30

$35

• No refunds or exchanges for HSA orders.

OAA

Outstanding Administrator Award

$30

$35

• Please do not send cash as payment.

AWARD RECIPIENT’S NAME – To appear on certificate

AWARD TYPE

ADD PIN

TOTAL

VSP HS CS GOS OT O

Yes No

Please Print Clearly

First Name

Last Name

SHIPPING & HANDLING

(1 - 5 Awards $5.00/ 5 - 9 Awards $7.50/ 10+ Awards $10.00)

TOTAL $

To order HSAs, send completed

METHOD OF PAYMENT

(Check appropriate box)

form with payment by mail or FAX:

CHECK or MONEY ORDER – Payable to Kustom Imprints

• A fee of $10 is charged for any check returned due to insufficient funds.

• Mail Orders:

• Two signatures are required on all PTA/PTSA checks.

California State PTA

c/o Kustom Imprints

MasterCard

VISA

1661 N. Glassell Street

Personal Credit Cards Only

Orange, CA 92867

Zip Code

___ ___ ___ ___ ___

• FAX Orders:

714.771.5798

___/___/___/___/ ___/___/___/___/ ___/___/___/___/ ___/___/___/___/

___ ___ / ___ ___

- Credit Card Only

Credit Card Number

Exp. Date

- Use blue/black ink for Fax Order

Print Name ________________________________________________________________________________________

• For Information, Call:

800.683.5854 ext.107

Signature __________________________________________________________________________________________

- No Phone Orders Accepted

FOR OFFICE USE ONLY:

Invoice #

_______________________________________________Ck # ___________________

AMT. _____________ q PTA q PER

5/2015

Order Online at ! You can also place an order and pay by check.

Forms

California State PTA Toolkit

Honorary Service Award (Hsa) Order Form

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