Mail to: Autism Society of America Pittsburgh

4371 Northern Pike Monroeville, PA 15146 

Name______________________________________________________________________ 

Address_____________________________________________________________________ 

City___________________________________State____________Zip___________________  

How many of each size?  ___M     ____L____XL_____ XXL 

Total number of shirts = ____________                Times 19.95 each           ____________ 

Total to appear on check  _______________