Autumn Harvest Internet Order Form
email:
http://www.autumnharvest.com


Note: Please PRINT clearly. Telephone and Signature are required on all orders.
Shipping Information: | Contact Information:
Name: _________________________________ | Telephone: _________________________
Addr:: _________________________________ | Signature: _________________________
_________________________________ | Order Date: _________________________
                 
_________________________________ | Payment Information:
_________________________________ | MC/VISA#: _________________________
_________________________________ | Exp. Date: _________________________
CVC Code (3 digits on back of card) _____________

All prices in US$

Dip/Salsa: $3.25

Breads: $4.99

Breading/Batter: $4.99
Product / Item Description Quantity Price each Total
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Internet Special! (Dip Mix) ______________ ___1___ FREE________ FREE___________
_________________________________ _______ _____________ ________________
Subtotal: ________________
UPS shipping anywhere in lower 48 states is only $6.95 Shipping: ________________
for the first 5 pounds. Total: ________________

Return to: Autumn Harvest Gourmet Foods 20249 High Hill Lane Joplin, MO 64801-9732 U.S.A.
Voice: 800.217.7140 (U.S.A.) Voice: 417.673.7623 Fax: 417.673.4097