Name: *
Company Name
Address: *
City: *
State: * (2 Letter) Zip: *
Home Phone: * Work Phone:
Fax: E-mail: *
Tax ID #
Credit Card #
Exp. Date This is not a secure site-Fax Credit Card Information Only
Item Size Quantity Flavor Price Each Total Price

Shipping & Handling
Up to : $9.95 add $5.50
$10.00 to $20.00 add $6.50
$20.00 to $30.00 add $8.50
$30.00 to $40.00 add $9.50
$40.00 to $60.00 add $10.95
over $60.00 add 15% of total

Order Total
Shipping & Handling
Virginia Residents add 4.5 %  Sale Tax
 
Grand Total

Special
Request

Print and fax this form to 1-540-778-1883 or
Submit Order Below and We Will Call For Credit Card Information
 

 

 
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