2007 15 Week Club		Fire or Ambulance Calls: 911
		Business Phone: 610-430-1554
	Goshen Fire Company 1320 Park Avenue, West Chester Pennsylvania 19380

Name: …………………………………………………………………..

Address: …………………………………………………………..

City, State, Zip: …………………………………………………………..

Phone: …………………………………………………………..

Email: …………………………………………………………..

# of Tickets Requested ____________ X $25 equals

Amount included: $ ________________

Remit to:

Goshen Fire Company

1320 Park Avenue

West Chester, PA 19380

Attn: 15-Week Club