Cyp Haven Order Blank

Cyp. Haven
22957 - 280th Street
Adel, IA 50003-4491
Phone: (515) 993-4841 Fax: (515) 309-2302 E-MAIL: slipperguy@aol.com

Please PRINT names and addresses!       Date

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Telephone:                                              E-mail:

Substitution OK?     No     Yes   (If "yes" please list)

Amount of
Check Enclosed

$
(or if preferred, check
one of the credit cards)     VISA

MasterCard


Your credit card account number



Expiration Date                                                        Security Code



Signature

QTY                     PLANT DESCRIPTION                       PRICE        TOTAL

SUBTOTAL

IOWA RESIDENTS ADD 6% SALES TAX

SHIPPING $  5.00

TOTAL

*Please PRINT names and addresses!*			Date

S O L D T O			S H I P T O



Telephone:			E-mail:
Substitution OK? No Yes (If "yes" please list)

Amount of Check Enclosed $ (or if preferred, check one of the credit cards)	VISA MasterCard
		Your credit card account number

		Expiration Date Security Code

		Signature

QTY	PLANT DESCRIPTION	PRICE	TOTAL












SUBTOTAL
IOWA RESIDENTS ADD 6% SALES TAX
SHIPPING			$ 5.00
TOTAL