POTTSTOWN POLICE DEPARTMENT

SHOULDER PATCH REQUEST FORM

(Please Print Clearly)

Name:                                                                                                                                                                                                         

Street Address:                                                                                                                                                                                        

State/Province:                                                                                         Country:                                                                                

Postal Code:                                                                                         (Note: We will ship world-wide / Payment must be in U.S. Dollars)

Phone Number (In case we have to contact you about your order):                                                                                                           

Shipping Address (if different than above):

Street Address:                                                                                                                                                                                        

State/Province:                                                                                          Country:                                                                               

Postal Code:                                                                                      

Number of  Pottstown Police Department Shoulder Patches Requested:

1                  =   $5.00 Check or Money Order payable to Pottstown Police Department (Shipping Included)

2                  =   $10.00 Check or Money Order payable to Pottstown Police Department (Shipping Included)

Mail this Order Form with your Check Or Money Order (Payable to Pottstown Borough) to:

Pottstown Police Department Administration

100 East High St.

Pottstown, PA  19464