Please fill in your name, phone number including area code and address.  Please print clearly.

Name  _____________________________________   Area Code  ___________ Phone No. ______________________

E-mail Address:_______________________________________ School Name_________________________________

Address  __________________________________________________________________________ Apt. # _________

City  ___________________________________________________  State  ________________    Zip ______________

Please fill in all 30 spaces with the code numbers showing your choices of coupons, starting with your first choice

in space #1.

  1________2_________3.________4.________5.________6.________7.________8.________9.________10._______

11_______12________13________14________15_______16_______17________18________19________20_______

21_______22________23________24 ________25_______26_______27________28________29________30_______

Please mail this certificate to:  “The American Way” , P.O. Box __________________________________, along with the $10 processing and handling charge and a self-addressed, stamped envelope for your $60

worth of coupons.  Allow 5-10 days for delivery of your coupons.

Please send me an updated Grocery Coupon list.  ____ Yes  ____ No