Coordinator Name:           __________________________________________

Email Address:                __________________________________________

School Group Name (if available):  ___________________________________

School:                           __________________________________________

School Organization to which check should be issued: __________________

Address:                         __________________________________________

City:                               __________________________________________

State:                             __________________________________________

Zip:                                __________________________________________

Phone Number:               (           ) _______ - ____________

Number of UPCs _________ X 5 cents (0.05) = $ ____________ Cash Total

Coordinator Signature:     __________________________________________

Date:                             __________________________________________

Aunt Millie's will add $1.00 to your total to assist in covering postage and insurance.