2010 BCS CHAMPIONSHIP COIN ORDER PLEASE PRINT LEGIBLY

1. 2010BCS CHAMPIONSHIP COIN ORDER PLEASE PRINT LEGIBLY Last Name: __________________________ First Name: ____________________________ Telephone #: (__ __ __) __ __ __ - __ __ __ __ Email: _______________________________ # Coins ____ x $35 per coin = $_________ Due Payment Information: ___ Cash ___ Check #: ____________________________ ___ Credit Card Type: ___MC ___VISA ___AMEX Card #: ________________________________________________________ Expiration Date: ______________ Sec Code:_______ Signature: _____________________________________________________ --------------------------------TO BE COMPLETED UPON RECEIPT OF COIN-------------------------------- I have received the number of coins ordered above. Signature: ________________________________ Date: __________________________ ----------------------------------------------------------------------------------------------- PROVISIONAL AUBURN CHAMPIONSHIP COIN If Auburn wins the National Championship Game, the Highland Mint will produce a special Championship Coin. This coin will be similar to the BCS Championship Game Coin, however will showcase Auburn only. The packaging and display cases will be similar. If you are interested in purchasing one or more of these coins, please indicate below. YOU MUST PROVIDE PAYMENT INFORMATION, HOWEVER, YOUR PAYMENT WILL NOT BE PROCESSED IF AUBURN DOES NOT WIN THE GAME. # Coins ____ x $35 per coin = $_________ Due Payment Information: ___ Cash ___ Check #: ____________________________ ___ Credit Card Type: ___MC ___VISA ___AMEX Card #: ________________________________________________________ Expiration Date: ______________ Sec Code:_______ Signature: _____________________________________________________ When coins arrive we will contact you via email. Please provide your email address: ___________________________________________________________________________