Kokopelli's Green Market Order Form

Kokopelli's Green Market
20 Farr Way, P.O. Box 353, Brandon, VT 05733
Phone (800) 210-0202 - - - Fax (802) 247-4114

Customer and Payment Information

Should you have any concerns about our use of your personal information,
we urge you to review our Privacy Policy.

E-mail: . State or Province: .

Name: . Postal Code: .

Address: . Country: .

: . Telephone: .

City: . Fax: .

May we contact you periodically via post or email to let you know about new products or special offers? Yes No

Payment Method:

American Express

MasterCard

Visa

Discover

Check

Money Order

Card Number: .

Card ID:
from reverse of card .

Expiration Date: .

Signature .

Note: Products must be shipped to credit card billing address on all credit card orders.

Products Ordered

Line Catalog
Number Description Quantity Price
Each Extended
Price

1 . . . . .

2 . . . . .

3 . . . . .

4 . . . . .

5 . . . . .

6 . . . . .

7 . . . . .

Product Total .

Shipping Charge .

6% Sales Tax (Vermont residents only) .

Total Remitted .

E-mail:	.	State or Province:	.
Name:	.	Postal Code:	.
Address:	.	Country:	.
:	.	Telephone:	.
City:	.	Fax:	.
May we contact you periodically via post or email to let you know about new products or special offers?		Yes	No

Line	Catalog Number	Description	Quantity	Price Each	Extended Price
1	.	.	.	.	.
2	.	.	.	.	.
3	.	.	.	.	.
4	.	.	.	.	.
5	.	.	.	.	.
6	.	.	.	.	.
7	.	.	.	.	.
Product Total					.
Shipping Charge					.
6% Sales Tax (Vermont residents only)					.
Total Remitted					.

Special Instructions