I would like to purchase ______ CHOOSE LIFE license plate holders at $25 each, including shipping and handling.   Thank you for helping Illinois to establish a license plate promoting Adoption as a Loving Option.

Please make your tax deductible check payable to ILLINOIS CHOOSE LIFE, INC and mail it with this form to the address shown above.

Enclosed is a check in the amount of  $________ for the plate holders and shipping fees.

Name __________________________________________________

Address ________________________________________________

 City, State, Zip ___________________________________________

 Phone (optional) __________________________________________