Uil Medal Order Form
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1UIL MEDAL ORDER FORM
Your school may obtain additional medals for participants by submitting a completed form to the
address/fax number below along with your payment: (check or credit card) or ISD purchase order.
Make checks payable to The University of Texas at Austin.
UIL – Order Department
Credit card (check one): VISA_______ MC_______ DISC______
PO Box 8028
Credit Card #________________________________________ Exp Date______________
Austin, TX 78713
Name of Cardholder: _______________________________________________________
Fax: (512) 232-6471
Zip Code to Bill Address:_______________________________
Email:
Signature_________________________________________________________________
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PRICE: Regional: 1
– 3
Place $7/ea; 4
– 6
Academic & 4
– 10
Cross Country $5/ea
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State: 1
– 3
place $11/ea; 4
– 6
Academic $5/ea; 4
– 10
Cross Country $7/ea
(price includes standard shipping & handling charges)
Duplicate this form if you are ordering more than one type of medal.
TO INSURE PROMPT AND ACCURATE SERVICE, PLEASE RESPOND TO ALL ITEMS BELOW
TYPE: Athletic ________ Academic ________ Music ________ One-Act Play _________
Contest/Sport:_____________________________________ Event
:_________________________________
(if applicable)
Year:________________ School: _______________________________________________________________________
Participants Name: __________________________________________________________________________________
Please check the appropriate blanks:
Quantity:
_____STATE
CONFERENCE:
st
Subtotal: $_______________
_____REGIONAL
_____1A
______1
Place (Gold)
nd
_____2A
______2
Place (Silver)
rd
_____3A
______3
Place (Bronze)
8.25% Sales Tax: $________
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th
_____BOYS
_____4A
______4
-6
(or attach sales tax exempt form)
(Academic only)
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_____GIRLS
_____5A
______4
-10
(Cross Country only)
_____6A
Total: $_________________
SHIPPING ADDRESS
BILLING ADDRESS
School: __________________________________________
School: _________________________________________
Attention: ________________________________________
Attention: _______________________________________
Street Address: ____________________________________
Address: ________________________________________
City, State, Zip: ____________________________________
City, State, Zip: __________________________________
Submitted by: _______________________________________Email address:____________________________________
Phone number: ______________________________________ Date:_________________________________________
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