(print and mail)
Date:_________________
Ordered by: Ship to (if different):
Name______________________________ ______________________________
Street______________________________ ______________________________
City/
State/Zip______________________________ ______________________________
Phone______________________________
How Many Size Grade Cost ______ ____________ _____________________ ____________ ______ ____________ _____________________ ____________ ______ ____________ _____________________ ____________ Total amount of order ____________
Please note that our prices include shipping and handling!
How do you wish to pay?
_____ check enclosed
_____ VISA _____ MasterCard
Credit Card No. __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date __ __ / __ __
Card Security Code __ __ __
(Flip your credit card over, find your 16-digit credit card number in the
signature box, followed by an additional 3-digit
Card Security Code.)
Signature: ________________________________________________
Be sure to specify an address to which UPS can deliver. We only ship within the United States.
If you would like your purchase shipped to another address (a gift, for example), just send us your instructions and, if you like, your own note or gift card to be enclosed with the syrup.
When you are ready to order, or if you have questions, contact us at one of the following:
Bill & Donna Putnam
Putnam Family Farm
145 Putnam Road
Cambridge, VT 05444
phone: 802-644-2267 e-mail: bputnam@sover.net WWW: www.putnamsvtmaplesyrup.com