Print the form below and write in your selections.
Please mail payment for purchases from this organization to:
UT ASP, College of Pharmacy
The University of Texas at Austin
1 University Station, A1900
Austin, TX 78712-0120
USA
(Note: All prices include shipping and handling charges. T-shirts are in adult sizes.)
Questions about the items may be sent to The College of Pharmacy. Please include the name of the organization selling the item in your message.
| Item Description | Item Price | Item Options |
|---|---|---|
| License Plate Frame | $16 | |
| Long Sleeve Grey T/ Blue Lettering | $19 | Select Size: M |
| Orange T/ Lettering and Bevo | $16 | Select Size: S M L XL |
| Blue Texas Pharmacy | $16 | Select Size: S M L XL |
| Grey Texas Pharmacy | $16 | Select Size: S L XL |
| Texas Pharmacy Polo | $18 | Select Size: S |
| Orange Hooded Sweatshirt | $25 | Select Size: S M |
| Blue Hooded Sweatshirt | $25 | Select Size: S M L |
| Grey Hooded Sweatshirt | $25 | Select Size: S M L |
| Texas Pharmacy Travel Coffee Mug | $12 |
Please enter the number of items you want to purchase of each option. If none, leave blank.
| License Plate Frame | ________ |
Medium Size Long Sleeve Grey T / Blue Lettering | ________ |
Small Size Orange T / Lettering and Bevo | ________ |
Medium Size Orange T / Lettering and Bevo | ________ |
Large Size Orange T / Lettering and Bevo | ________ |
Extra Large Size Orange T / Lettering and Bevo | ________ |
Small Size Blue Texas Pharmacy |
________ |
Medium Size Blue Texas Pharmacy |
________ |
Large Size Blue Texas Pharmacy |
________ |
Extra Large Size Blue Texas Pharmacy |
________ |
Small Size Grey Texas Pharmacy |
________ |
Large Size Blue Grey Pharmacy |
________ |
Extra Large Size Grey Texas Pharmacy |
________ |
Small Size Texas Pharmacy Polo |
________ |
Small Size Orange Hooded Sweatshirt |
________ |
Medium Size Orange Hooded Sweatshirt |
________ |
Extra Large Size Orange Hooded Sweatshirt |
________ |
Small Size Blue Hooded Sweatshirt |
________ |
Medium Size Blue Hooded Sweatshirt |
________ |
Large Size Blue Hooded Sweatshirt |
________ |
Extra Large Size Blue Hooded Sweatshirt |
________ |
Small Size Grey Hooded Sweatshirt |
________ |
Medium Size Grey Hooded Sweatshirt |
________ |
Large Size Grey Hooded Sweatshirt |
________ |
Extra Large Size Grey Hooded Sweatshirt |
________ |
| Texas Pharmacy Travel Coffee Mug | ________ |
| Total number of long sleeve shirts- $19 each | ________ |
| Total number of t-shirts - $16 each | ________ |
| Total number of license plate frames - $16 each | ________ |
| Total number of polos - $18 each | ________ |
| Total number of hooded sweatshirts - $25 each | ________ |
| Total number of coffee mugs - $12 each | ________ |
| Total amount due | ________ |
Please submit checks payable to UT-APhA-ASP; and, provide the address where the items are to be shipped:
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Name:__________________________________________________________
Email:__________________________________________________________
Phone Number (including area code):________________________________