Cauliflower Publishing Company­­Order Form

This is a simple two page printable form for ordering via fax, regular mail, email, or for requesting a catalog. To order via fax or regular mail: 1) Select options in ALL pulldown menus BEFORE printing form, 2) type in text blocks (or print form and fill in by hand)

To order via email, hit "submit" after typing in all information. Otherwise, print and fax; or print and mail.

Select Form Submission Option Here Print & FAX: 360.332.9871 Print & MAIL: 8437 Catalina Ct., Blaine, WA 98230 Phone the order: 360.332.9835 Email to order to: order@cauliflowerear.co Request a Catalog at:catalog@cauliflowerear.com

Last Name:

First Name:

Street Address: Apt.

City: State: Zip Code:

Email: URL:

Telephone: Fax:

Would you like:our product catalog? notification of new products?

To place an order, fill in purchasing information.

Select Payment Method VISA Mastercard Enclosed Check Enclosed Money Order Number:

Name on Credit Card: Expiration Month January February March April May June July August September October November December Exp. Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Please enter product information on Page 2, below:

Order Form­­Page 2

Type product information, or print form and enter information by hand:

Order Number

Product Name/Description

Quantity x

Unit Cost =

SubTotal

Calculate totals with your own calculator. Type or hand write totals below.

Sum of Subtotals:

Add Shipping @ .08%:

WA Residents Add .078% Sales Tax:

Grand Total: