POT OF GOLD COFFEE    ORDER FORM

NAME:____________________________________________________________

TELEPHONE:(_____)________________________________________________

ADDRESS:_________________________________________________________

CITY:_____________________ PROVINCE:______ POSTAL CODE:__________


Please send me the following order postage free* at an interval of every 2 - 4 - 6 - 8 - 10 - 12 weeks (please circle one)

COFFEE VARIETY                  QUANTITY (in lbs)                $ / lb                 TOTAL

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

POSTAGE: $ ________7.00**__

ORDER TOTAL: $ __________________

* for us to provide you with this free service, we must have a minimum order of two pounds per shipment on a subscription basis. (Manitoba east 3# min.)
** Please do not add this amount if you are committed to a standing order

PAYMENT OPTIONS:

I prefer to pay by:
Cheque _____

Or, please charge my shipment to:

Mastercard # ______________________________________ Exp: _____/_____

Visa # ___________________________________________  Exp: _____/_____

Mail To: Pot of Gold Coffee Company, Box 1-7, Thetis Island, BC V0R-2Y0