Date:   ______________

Ship to:   ____________________________________________________________________

Street:.   ____________________________________________________________________

City:   _____________________________________ ST ________ ZIP ___________________

Phone: _____________________________E-Mail:___________________________________

Quantity                      Name of Variety                                                         Price        

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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     Side 2 Total   ________________________________________

     Subtotal       _________________________________________

     5.725% Sales Tax - MO Residents Only ____________________

     Postage and handling ______________________   $6.50

     Total payment Enclosed ______________________________
 
     In the event we are sold out of a variety, may we:

     Substitute   __________ Refund __________