Duplicate Award Order Form

Award Information

Award Year: *

Award Category: *

Station Name: *

Title of Winning Entry: *

Contact Information

First Name: *

Last Name: *

Address: *

Suite:

City: *

Province/States: *

Country: *

Postal Code/Zip Code: *

Phone: (Please include area code) *

Email: *

Shipping Information

Use Contact Information

First Name: *

Last Name: *

Address: *

Suite:

City: *

Province/States: *

Country: *

Postal Code/Zip Code: *

Fee Selection*

Network/National Award

$150.00 + HST

Regional Award

$85.00 + HST

PAYMENT INFORMATION

Subtotal:

$0.00

Tax:

$0.00

Total:

$0.00

Payment Method:

Name on Card: *

Credit Card Number: *

CVC: *

Expiration (MM/YYYY): *

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RTDNA Canada Portal

Membership & Event Registrations

Duplicate Award Order Form

Award Information

Contact Information

Shipping Information

Fee Selection*

PAYMENT INFORMATION