Policy & Procedure
SAC 04.00
Appendix B
Document Number
Member Leader Excellence Award –
Order Form
Revision B – 02/15/12
Please include name(s) and member number(s) for
each recipient below. Names should be listed as you
would like them to appear on the award.
Member Leader
Excellence Award
If this is a team award, please list the team name as
it should appear on the award and year of service.
Use this award
for recognition of
Member Leaders
Shipping and handling charges apply to each
award ordered in the following amounts:
Recognize member individuals
or teams for their outstanding
commitment to ASQ
and their communities
Quantity
1
2
U.S.
$6.50
$12.50
Canada
$11.50
$17.50
Others
$14.75
$29.50
Inscription:
In recognition of your commitment
and outstanding contributions to your
ASQ section and your community
(Size 4-1/4 inches x 7-1/4 inches)
SECTION
ORDERING
MEMBER
Name
Number
Name
Number
Address
SHIPPING
ADDRESS
Item number
R104 N
City
State/Province
Quantity
MC
PAYMENT
Visa
AMEX
Purchase order
Check
Zip/Postal Code
Cost per item
$59 plus shipping and handling (see above)
Total
Number
Exp. Date
Number
Name/Team
Member Number
AWARD WINNER
Member Status
Name/Team
Member Number
AWARD WINNER
Member Status
Limit of two awards per Member Unit each fiscal year.
Awards will be shipped 30 days after order is received.
SUBMIT TO:
Along with MLEA
application form
Mail
ASQ
Community Development
600 N. Plankinton Ave.
Milwaukee, WI 53201
Date Needed
E-mail
community development@asq.org
Fax
414-765-8670
All orders received by February 28th will be included in the Honors and Awards Brochure at the World Conference on Quality and Improvement.