Please print out this form and send it to:

Brian Dyer
Rose-Hulman Institute of Technology
5500 Wabash Avenue
Terre Haute, IN 47803

Name _______________________________

Address _____________________________
____________________________________
____________________________________
____________________________________

Yearbook Year(s)______________________

Quantity ____________________________

Cost: $3 for shipping and handling

Total: ______________________________

If you wish to pay with a credit card please call
Trudy Sladek at (812) 877-8976