ORDER FORM: DATE: __________________

Name: _________________________________________________________

Address: ________________________________________________________________________________
________________________________________________________________________________

Telephone: ___________________________________

Email: __________________________________

___ Half Box

___ Whole Box

Date Desired: ______________________

Farm Pick-Up Date & Time: ________________________________________

Special Instructions/Requests: __________________________________________________________
THANK YOU FOR YOUR ORDER!!!

Order Details:
__ Half Box ___ $200.00
__ Whole Box ___ $380.00

2.5% VA Sales Tax: ___ $________
Farm Pick-Up Regular FREE
Farm Pick-Up Custom ___ $ 25.00
Delivery (within 60 miles) ___ $100.00

50% Non-refundable box deposit: ___ $100.00
___ $190.00
5% Discount for Pre-payment of Total ___ $ 10.00 Half Box
___ $ 19.00 Whole Box
SUBTOTAL ___ $________
2.5% CC Fee ___ $________
TOTAL: ___ $________
Name on Card:
Card Number:
Expiration Date:
Security Code:
Zip Code:
THANK YOU FOR YOUR ORDER!
Farm Notes for this Order