PRINT THIS PAGE FOR EACH RECIPIENT

FAX Order Form

PURCHASER INFORMATION

PLEASE TYPE OR PRINT LEGIBLY

(Personal 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 and email address 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_________________________________________________________________________________________