First Name:    Last Name:

Todays's date (mm/dd/yy):

Phone no.    Fax no.    Voice Mail:

E-mail:

Address:

City:    Province:    Postal Code:

My       son's / daughter's     name is

I have  other children

Please engrave the back of the Coin with frist name and date

Contact: DUANE ROSET

• Bus 403-526-9550
• Bus 888-646-8242
• Fax 403-529-6793
• m@roset.net