R cei bela inaiaebnstion
Name of Purchaser | AVL. Cx : Hae SHAM Issue &
Address 24 +2. NN. LH KRHP SHIRE Amount 19'sSo0 og
Tits € Fx ek Noctrssbin: Pao K Dates holes ‘oe

yz. Seach al a ar a die a ea eS ete
(Credit—Organization or Team) ~ (Solicitor)
(Solicitor should deliver to Committee Chairman or Captain, as instructed.)