PAYMENT MUST ACCOMPANY ORDER! Also checks must be drawn on a US BANK. If not you must add $15.00(US)
to your order to cover the cost of our Bank's Foreign Check Collection Fee. If your club placed an order, we should have
their club roster on file. If not, your club rep will be contacted to provide one before your order can be filled. Please have
an officer or the NCC rep of your club sign this form to certify your current membership in an NCC club. Please include
this form with your payment and send to:

                                                         National Council of 56 Clubs (NCC)
                                                         22 Samoset Rd.
                                                         Orleans, MA 02653


CLUB NAME: _____________________________________________ STATE: ___________

MEMBER ORDERING: ________________________________________________________

ADDRESS (no PO Boxes)_______________________________________________________

CITY, STATE, ZIP: ____________________________________________________________

TELEPHONE: (______)______________ E-MAIL: ___________________________________

PLEASE ACCEPT MY ORDER FOR  ______  JACK'S UMBRELLA SHOPS at $66.00(US) each TOTAL $ ____________

There is a limit of 2 per member. The cost of $66.00 includes shipping and handling. US deliveries are sent via UPS. Canadian sales will be sent via USPS Priority Mail. Orders are filled on a first-come first served basis WHILE QUANTITIES LAST. Your signature below signifies that you are a member in good standing of a current NCC member dub and also understand that all breakage must be reported to the NCC within 15 days of delivery for the claim to be honored.


                                        Signature of Purchaser Member


                                        Signature of Club Officer/NCC Rep verifying the

                                        above purchaser is a member in good standing

                                        of the club named herein.

TOTAL AMOUNT ENCLOSED $_________________    


For NCC Use Only:

      Order taken by: _________________________________ Cash __________Check  __________

    Gathering name:____________________________________ Order Date:__________________

For NCC Treasurers Use Only:

    NCC 2002 Dues Current?:___________________ Roster on file?:________________

              Date order shipped:________________________________________________