| Name | ___________________________________________ | Phone | (_____) ______________ |
| Address | ___________________________________________ | _____________________ | |
| City/State/Zip | ___________________________________________ | NSA# | _____________________ |
| Special Requirements _________________________________________________________________ | |||
| LUNCH SELECTION (CIRCLE ONE) A B C D | ||
| CHOICES | A | Sliced turkey, cheese, lettuce & tomato sandwich |
| B | Sliced ham, cheese, lettuce & tomato sandwich | |
| C | Sliced roast beef, cheese, lettuce & tomato sandwich | |
| D | Veggie wrap | |
| Each choice includes condiments, bag of potato chips, piece of fruit, & 2 cookies | ||
| If you have any special dietary needs, please specify. | ||
| SELECTION (CIRCLE ONE) A B C D |