Beep T-Shirt Order Form

Farmers DairyPO Box 8118Halifax, NSB3K 5Y6

Payment

Credit Card

Visa

Mastercard

Card Number:

Expiration Date:

Cardholder Name:

* $20/Shirt (includes tax& shipping) *Allow 6-8 weeks for delivery

Date:

Customer Information

Name:

Address:

City:

Province:

Postal Code:

Phone

E-mail:

Forms can be submitted by:

Internal Use Only

Ship Date:

Order Completed:

* Mail *Fax(902) 835-1583

*E-mailscan & e-mail to merchandise@farmersdairy.ca

Size Quantity Unit Price Amount

Grand Total

S

M

L

XL

XXL