PRINT THIS PAGE FOR EACH RECIPIENT
FAX Order Form
PURCHASER INFORMATION
PLEASE TYPE OR PRINT LEGIBLY
(Persoanl info only need be filled in once if placing multiple orders)


Name_______________________________

Address_____________________________

   Suite/Apt#_________________________

City, ST, Zip__________________________

Day Phone___________________________

Eve Phone___________________________

E-mail Address______________________________

It may be necessary to contact you about your order.
Your phone number will be held in confidence.
 

      
 Discover/Visa/Mastercard/AMEX
      Number

      
Expiration
 
 

_________________________________________
Signature

Shipping Charges

      
 1/4 lb.

      

								$ 6.10

      
  1/2 lb.

      
 $ 6.10

      
  1 lb.

      
 $ 7.50

      
  2 lb.

      
 $ 9.30

      
  3 lb.

      
 $ 11.00

Gift Description to be shipped to following address:_________________________

 

      
 Qty

      
  Price

      
  Subtotal

      
  Shipping

      
  This Gift
      Total
 
 
 
 
 

SHIP TO:

Name__________________________________________         Greeting:________________________________________
                                                     (Please limit to 15 words)
Address________________________________________

            ___________________________________

City, ST, Zip______________________________________