Order Form For H&R Coffee
Please PRINT this form and fill out the order information completely.
Any omitted information may inhibit shipment of your order.

ORDERED BY:   Name _______________________________________________________   Date: ____________

Address ___________________________________________________________________________________________________

City __________________________ State ________ Country ______________ Zip Code ____________

Work Phone (      )______________________________ Home Phone (      )_____________________________

E-Mail Address ____________________________________________________

SELECT METHOD OF PAYMENT: Payable to H&R Coffee

__ Check/Money Order __ Visa  __ MasterCard __ Discover __ American Express

Name of Card Holder__________________________________ Signature _______________________________________

Account # _______________________________________    Expiration Date MONTH _________ YEAR_______

SHIP TO:  Name _____________________________________________ Use same info. as above: ______

Address ___________________________________________________________________________________________________

City __________________________ State ________ Country ______________ Zip Code ____________

Work Phone (      )______________________________ Home Phone (      )_____________________________

NAME OF ITEM

QUANTITY

UNIT PRICE

TOTAL
       
       
       
       
       

  Add $2.00 for Rush Orders

   

  SUBTOTAL
($25.00 Minimum)

   

                      UPS SHIPPING CHARGES DEPEND ON ORDER SIZE 
                                            For orders from  $25.00 -  49.99, add $4.50 for shipping 
                                             For orders from $50.00 -  99.99, add $7.25 for shipping 
                                            For orders over $100, add $8.50 for shipping

  

ORDER TOTAL

  

____ Yes, send me a surprise sample at no charge!

There are 4 ways to order:

#1) Contact one of our Customer Service Representatives at
1-800-4-PERKS-2
(800-473-7572)

#2) Send an e-mail to shartley@coffeeperks.com
telling us what items you would like.


#3) Print and FAX this form to us at (904) 737-7946

#4) Or print and mail this form,
along with your money order or credit card information to:

H&R Coffee Company, Inc.
2985 Mercury Road
Jacksonville Florida 32207

Thank You For Your Purchase!

 

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