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Please fill out the following and mail to:

MARISSA HISTORICAL AND GENEALOGICAL SOCIETY
P.O. Box 245
Marissa, IL 62257-0245
U.S.A.

Please send me ____ T-Shirts @$15.00 each = ___________
  Requested Size or Sizes: _____________________________
Please make checks payable to: Marissa Historical and Genealogical Society

Mail the T-Shirt to:

NAME: _________________________________________________________________________
ADDRESS:_______________________________________________________________________
CITY:__________________________________________________________________________
STATE:   ____________________  ZIP CODE:  ___ ___ ___ ___ ___ + ___ ___ ___ ___
COUNTRY:   _____________________________________