EmailMeForm
Black Nurses Association Order Form
Please verify your information before submitting this form. Most fields on this form are required. Select NA or 0 for those areas not applicable.
You can pay via Venmo, CashApp, Cash, Zelle, or PayPal.
Venmo: @Dianne-Ricks
CashApp: $DeeWayRicks
PayPal: @DianneWay or dwayricks@yahoo.com
Zelle: 504-430-3389
Name
*
First
Last
Floor/Unit
*
Cell Phone/Work Phone #
*
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Email
*
DriFit Shirt Color
*
Black
White
Red
NA (Ordering Cotton Shirt)
This is a multiple choice field. You are able to select multiple shirt colors.
Shirt Size: Price includes shirt, logo, and your name. If you don't want your name on your shirt, deduct $3.00/shirt from your total.
*
XS ($35.00)
Small ($35.00)
Medium ($35.00)
Large ($35.00)
XL ($35.00)
2XL ($37.00)
3XL ($37.00)
4XL ($40.00)
NA (Ordering Cotton Shirt)
The DriFit Shirts RUN LARGE so please make sure you select the correct size.
# DriFit Shirts Ordered (0 If ordering Cotton)
*
DriFit Shirt Total:(0 If ordering Cotton)
*
Calculate the number of drifit shirts ordered by the cost and place that value in this field
Name on DriFit Shirt or Other Info. (NA if ordering Cotton)
*
Please double check this information for accuracy before submitting the form.
Cotton Shirt Color (Skip this entire section if you are not ordering a cotton shirt)
Black
White
Red
This is a multiple choice field. You are able to select multiple shirt colors.
Cotton Shirt Size: Price includes shirt, logo, and your name. If you don't want your name on your shirt, deduct $3.00/shirt from your total.
Small ($23.00)
Medium ($23.00)
Large ($23.00)
XL ($23.00)
2XL ($25.00)
3XL ($25.00)
4XL ($28.00)
# Cotton Shirts Ordered
Cotton Shirt Total:
Calculate the number of cotton shirts ordered by the cost and place that value in this field
Name on Shirt or Other Info if ordering Cotton Shirt
Please double check this information for accuracy before submitting the form.
Total # of Shirts Ordered (DriFit+Cotton if applicable)
*
Add up the number of DriFit + Cotton shirts ordered and place that value in this field.
Total Amount Due: (Total For DriFit + Cotton Shirt if applicable)
*
Add up the DriFit Shirt Total + the Cotton Shirt total and place that amount in this field.
Please indicate your Payment Method
*
Venmo
CashApp
PayPal
Zelle
