Peaked Mountain Farm Order Form
Mailing
Address Shipping
Address
Name:_________________________ Name:______________________________
Address:_______________________ Address:____________________________
______________________________ ___________________________________
City:__________________________
City:_______________________________
State:_______
Zip Code:___________ State:________ Zip
Code:______________
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Item
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Description |
Price
Each |
Quantity |
Total
Amount |
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Tax |
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Shipping |
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Up to
$12.00 $7.95 |
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Merchandise
Total = |
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$12.01 to
$35.00
$11.95 |
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Shipping/Packing
+ |
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$35.01 to
$55.00
$13.95 |
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Taxable
Subtotal = |
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$55.01 to
$75.00
$14.95 |
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Tax + |
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$75.01
to $150.00 - $14.95 PLUS 10cents for each $1.00 over $75.00 |
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Total
Amount Due = |
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Check which payment method you prefer.
Check or money order enclosed. Charge to my credit card:
MasterCard Visa American Express
Credit Card # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Three or four digit security code (on back of card) ___ ___ ___ ___
Expiration Date:___________ (MM/YY)
Sign your credit card signature here: _______________________________________________
Card holders name as it appears on card (please print) _________________________________
Please print and
complete form. You may either mail to:
Peaked Mountain Farm • 16 Ellery’s Lane •
Or Fax to: (207) 843-6484