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ORDER PLACED BY:
Name: ________________________________________________________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Daytime phone number: ___________________________________________
E-mail: ___________________________________________
CREDIT CARD INFORMATION:
Visa ___
MasterCard ___
American Express ___
Discover ___
Money Order/Check Enclosed - Amount: $____________
Name of Cardholder: ________________________________________________
Account #: _______________________________ Expiration Date: ___________________
Signature: __________________________________________________________
Please fill out if the Name or Address above is different than the name or address on Credit card:
Name:________________________________________________________________
Address: ______________________________________________________________
City, State, Zip: _________________________________________________________
Daytime phone number: ___________________________________________
Shipping address if different than the name and address listed above:
Name:________________________________________________________________
Address: ______________________________________________________________
City, State, Zip: _________________________________________________________
Daytime phone number: ___________________________________________
E-mail: ___________________________________________
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If you normally clean 20 lb of chitlins, you should purchase only 1/2 that amount from us.