Person Requesting and Responsible for Sammy Otter

                           
                        Last Name                                                          First Name                         Middle Initial

     
       Mailing Address - Street or Post Office Box

        Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV                                               
                          City                        State                                        Zip Code

            Please type phone numbers in the following format:  (###)###-####
                                               
      Home Phone (including area code)           Cell Phone (including area code)

              Division &  Flotilla Number  Select 1-1 1-2 1-4 1-6 1-10 1-11 2-1 2-2 2-5 2-6 3-1 3-2 3-4 3-7 3-8 3-10 3-13 3-15 3-16 5-2 5-3 5-4 5-5 5-6 5-7 8-1 8-3 8-4 8-5 8-8 9-1 9-3 9-5 9-6 9-7 11-1 11-2 11-4 11-5 11-8 15-3 15-5 15-6 15-7 15-8 16-1 16-2 16-3 16-6 16-7 16-9 30-1 30-2 30-4 30-5 30-7 30-13 31-2 31-6 31-9 33-1 33-2 33-3 33-4 33-5 33-6 33-7        Member Number  
             E-mail address (required)

      Dates Needed: View calendar
                                                                                                                                                     
      From:        To:  

       From:       To:   

 

    Ship To Information

Check here if Shipped To Information is the same as Person Requesting and Responsible for Sammy Otter.  If the box is checked it is not necessary to complete the section below.

                     
                        Last Name                                                          First Name                         Middle Initial

     
       Mailing Address - Street or Post Office Box

        Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV                                               
                          City                        State                                        Zip Code

            Please type phone numbers in the following format:  (###)###-####
                                               
      Home Phone (including area code)           Cell Phone (including area code)

              Division &  Flotilla Number  Select 1-1 1-2 1-4 1-6 1-10 1-11 2-1 2-2 2-5 2-6 3-1 3-2 3-4 3-7 3-8 3-10 3-13 3-15 3-16 5-2 5-3 5-4 5-5 5-6 5-7 8-1 8-3 8-4 8-5 8-8 9-1 9-3 9-5 9-6 9-7 11-1 11-2 11-4 11-5 11-8 15-3 15-5 15-6 15-7 15-8 16-1 16-2 16-3 16-6 16-7 16-9 30-1 30-2 30-4 30-5 30-7 30-13 31-2 31-6 31-9 33-1 33-2 33-3 33-4 33-5 33-6 33-7        Member Number  
             E-mail address (required)

    Comments, questions, special requests and/or shipping instructions
               

If you have questions, contact Betty Zoellner, DSO-PA (any ADSO-PA) or include your questions in the "Comments, questions, special requests and/or shipping instructions" section above.