Fax / Mail Order Form

This is not an on-line form. It is a printable form for your convenience.

Please PRINT clearly.... especially if sending via FAX

Date: ______________

Fax to: (518) 732-4487  or Mail to: Gem Farms Buffalo, 1333 Van Hoesen Rd., Castleton, NY 12033
or Call: (518) 732-7452

 

Order From

Name: Phone:
Street Addess: Fax:
City: E-Mail:
State: Best time to reach you:
Zip:  

Ship To (if different than ordered from)

Name: Phone:
Street Address: Fax:
City: E-Mail:
State:  
Zip:  

Order Information

Item Number Description

Qty

Cost/Unit

 Total
         
         
         
         
         
         
     

Subtotal:

  
Shipping Charges

(please call)
Grand Total  

Please Note: Applicable shipping charges will be added to your order for packaging / dry ice / and UPS shipping. If prepaying by check, please call for shipping charges.

Choose Method of Payment
__ Check enclosed (for mail orders only - call for shipping charges before mailing check)
__ VISA    __ MasterCard    __ Discover Card

Credit Card Number:

                                

My Card Expires:    Mo. ______ Yr. ______
Signature: ___________________________