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Gift Order Form

DATE ______________
Sender’s Name ___________________________________________________________________
Address ________________________________________________________________________
City ___________________________________ State ________ Zip Code _________________
Phone ( ______ ) _________________________ Fax ( ______ ) ___________________________

Method of Payment: Mastercard Visa AMEX


Credit Card # _________________________________________ Exp. Date: ________________
_
Name on Card ______________________________ Signature ____________________________

Ship To ________________________________ Ship To ________________________________


Address ________________________________ Address ________________________________
City ___________________________________ City ___________________________________
State ______ Zip Code _________________ State ______ Zip Code _________________
8oz _____ 8oz Holiday _____ 1lb _____ 13/4 lb _____ 8oz _____ 8oz Holiday _____ 1lb _____ 13/4 lb _____

Message ________________________________ Message ________________________________


_________________________________________ _________________________________________

Ship To ________________________________ Ship To ________________________________


Address ________________________________ Address ________________________________
City ___________________________________ City ___________________________________
State ______ Zip Code _________________ State ______ Zip Code _________________
8oz _____ 8oz Holiday _____ 1lb _____ 13/4 lb _____ 8oz _____ 8oz Holiday _____ 1lb _____ 13/4 lb _____

Message ________________________________ Message ________________________________


_________________________________________ _________________________________________
COST S&H TOTAL

_________ 8 oz. Gift Tins $17.95 $6.95 _________


_________ 8 oz. Holiday Gift Tins $17.95 $6.95 _________
_________ 1 lb. Gift Tins $28.50 $6.95 _________
_________ 1 3/4 lb. Holiday Gift Tins $45.00 $6.95 _________
TOTAL: _________
To place an order: Complete this form and fax to (903) 533-9895
For longer gift lists, you may attach a mailing list with above information for each recipient.
P.O. BOX 9686 • Tyler, TX 75711 • email: info@txmoon.com