SIGNATURE BLAZER COMPANY

OMEGA PSI PHI (38-52)

Friendship is Essential to the Soul Please Order Before May 15th to Ensure Your Size Availability

Name:___________________________________________________
Chapter of Initiation:___________________Year:_______________
Current Chapter:______________________ (38-52)
Address:_________________________________________________
__________________________________________________
City:_______________________State:__________Zip:___________
Email Address:____________________________________________
Phone Number:__________________Alternate:_________________
Items being Purchased: (PLEASE CHECK YOUR SELECTIONS BELOW)
1-10Form per Brother***
***Please use one Order
$150 $150/each ACCEPTED METHODS OF PAYMENT: Visa, Master Card, American Express
The Omega Psi Phi Offical Centennial Blazer reg $249 $149 and Checks (should be made payable to Signature Blazer Company.)
Gold Blazer Purple Blazer
***Enter Raffle to Win Centennial Blazer 1911-2011*** $20
Embroidered Name $50 Visa Master Card Amex
# Request: (#1-2011)
1st_____2nd_____ $25
*Special Centennial Package: $100
(Executive dress shirt, Carrington wool pants, and the Official Centennial tie.) Expiration Date
-White 100% Egyptian, Cotton Dress Shirt with English Collar and French Cuffs
I, (your name)_______________________________,authorize Signature Blazer Company to
-Cream 100% Wool Light-weight Single-pleated Pants with Unfinished Bottom
charge the above credit in the total amount of $___________for the products listed above and
Free Delivery at Conclave Free Delivery shipping charges.

Standard Shipping $30 Cardholder’s Signature:_______________________________________

$ Date: _______________________________________
Total Amount: Please Mail or Fax Orders
2255 Peachtree Road NE Suite G. Atlanta, Georgia 30309 email: omega@signatureblazercompany.com www.signatureblazercompany.com
phone: 404-351-1773 fax: 404-351-1774