(* Indicates required
information)
Ordered By:
*Name:______________________________________________________________
*Street
Address:______________________________________________________
*City/Province:________________________________________________________
*Postal
Code:_________________________________________________________
Phone Numbers: Home:____________________ Business:___________________
Fax:______________________ Cell:______________________
*E-mail:_______________________________
*Payment Method:
Credit Card#:_______________________________
Expires:_______
CVD
#:_____________ (CVD # is the last three
digits on back of credit card)
*Shipping
Method:
Mail:____ Bus:____ Courier:____
In-store pickup:____
If you would like to know
the cost of shipping ahead of time please indicate here: [ ]
Delivered To
(Only if delivery address is different):
*Name:_____________________________________________________________
*Street
Address:______________________________________________________
*City/Province:_______________________________________________________
*Postal
Code:________________________________________________________
Phone Numbers: Home:____________________ Business: __________________
Fax: ______________________Cell:_____________________
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*Type of Coffee |
*Type of Tea |
*Amount in Pounds[ ] Or Grams[ ] |
*Type of Grind (coffee only) |
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