Goughryn Farm, Inc.

Order Blank

(print page & fill out to order)

Phone: 908-879-5121 Fax: 908-879-5145

E-Mail: wcogger@goughryn.com

Billing Information Ship To Information
Name ________________________ Name _________________________
Ad1 _________________________ Ad1 __________________________
AD2 _________________________ Ad2 __________________________
City __________________________ City ___________________________
State/Zip ___________________ State/Zip ____________________
Your Phone # _____________________________ Your E-Mail _______________________________________

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Sub Total
New Jersey residents Sales Tax (non food items) 6%
Shipping Cost (see below)
Total

We accept Checks, Credit cards Visa, MasterCard, AMEX and extend terms to business and local customers.

Credit Card Type ________________________

Number _________________________________

Expiration Date _______ ______ _______

Shipping Cost (48 contiguous states)
Sub-Total Regular 2day Rush
up to $15.00 4.50 10.50 14.50
15.01 to 30.00 6.50 12.50 16.50
30.01 to 50.00,/td> 8.50 15.50 19.50
50.01 to 100.00 12.50 18.50 24.50
Over $100.00 please call

Sign and Date Below (Must for all CC and terms orders)

__________________________________________ ______ ______ ______