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Mail-Order Form

Customer Information:
First Name: Last Name:
Shipping Address:

Telephone:
E-Mail:

Order Information:
Order Date:

Item Code Description Qty Unit Price Total Amount


CSWCOB (350pc) Vanilla Fortune Cookies _______ x $ 12.85 = $ _________

CSWCIB (350pc) Citrus Fortune Cookies _______ x $ 12.85 = $ _________

CSWCHB (350pc) Chocolate Fortune Cookies _______ x $ 14.20 = $ _________

CSWTF (350pc) Tri-Flavor Fortune Cookies _______ x $ 14.20 = $ _________

Shipping & Handling Charge Qty Unit Price

UPS Ground _______ x $ 27.00 = $ _________

Total: = $ _________

Payment Method:
Credit Card Only; No Check Accepted
Credit Card Information:
Billing Address:

Credit Card #: Expiration:


*** Name on card if different: ☺ Please fax order form to (718) 628-7788

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