Gorge Top
Gardens
P.O. Box 218 Coeburn VA 24230 - Fax 1-276-395-2371
Phone 1-276-395-2370
Print this form and use it for reference when placing your order by MAIL or FAX it to us.
| (A) Ship To: (name and address) We ship via UPS Ground - we will email tracking # |
(B) Bill To: (please fill in bill to
information if this differs from your shipping address) |
| Name: _____________________________ | Name: _________________________ |
| Address: ___________________________ | E-mail: _________________________ |
| Address:____________________________ | Address: ________________________ |
| City:________________________ State:___ Province:______ Zip:______ Country:_______ |
Address: ________________________ |
| Telephone:__________________________ | City:_____________________ State:___ County:________ Zip:____ Country:_______ |
| E-mail: _____________________________ | Daytime Telephone:________________ |
| Above information must match your issuing banks records when using a credit card. |
(C) List of Items:
| Item #: | Item Name: | Qty: | Price each | Total: |
Continue to next page to provide us with your shipping and billing details
(D) Totals & Shipping:
Shipping is one flat rate for all orders.
Please add $10.75 for shipping on all orders.
Shipping Season begins week of 3/21 and continues through the last week of May
Please give us your desired shipping date _______________________________
| Merchandise Total:_______________ | |
| Shipping $10.75 | |
| ONLY add 4.5% sales tax if you are a resident of Virginia:_______ | |
| TOTAL:_______________ |
(E) Method of Payment:
___ Check or money order (payable to "Gorge Top Gardens")
___ Mastercard ___ Visa ____Discover
Credit card #____________________________ & exp. date:____________
800 # on back of credit card__________________________
I agree to pay the above total amount according to card issuer
agreement X_________________________Date_______
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