Ben & Jerry's Gifts By Mail
19 Gregory Drive, South Burlington, VT 05403 - (866) BJGIFTS - FAX (802) 864-9846
Print this form and use it for reference when calling in your order or mail or FAX it to us.
(A) Sold To: (Your name and address)

Name: ____________________________________

E-mail: ________________________________

Street Address: ___________________________

____________________________________

City:________________ State:___ Zip:________

Daytime Telephone:_______________________

 (B) Ship To: (if different from sold to)

Name: ____________________________________

Street Address: ___________________________

____________________________________

City:________________ State:___ Zip:________

Delivery Address Telephone:_____________________

(C) List 'O Stuff:
Item #: Item Name: Size: Color: Quantity: Price per Item: Total:
___________________ ______________________ _____ __________ ________ ___________ _________
___________________ ______________________ _____ __________ ________ ___________ _________
___________________ ______________________ _____ __________ ________ ___________ _________
___________________ ______________________ _____ __________ ________ ___________ _________
___________________ ______________________ _____ __________ ________ ___________ _________

(D) Totals, Taxes, Shipping:

Merchandise Total:________
VT State Residents: add 5% Sales Tax on merch. delivered in VT:________
Shipping (see chart):________
purchase amount: shipping:
up to $25.00 add $4.00
$25.01-$40.00 add $5.00
$40.01-$60.00 add $6.00
$60.01-$80.00 add $7.00
$80.01-$100.00 add $8.00
$100.01-$150.00 add $10.00
$150.01-$200.00 add $12.00
over $200 add $15.00
TOTAL:_______

(E) Method of Payment:
___Check or money order (payable to "Ben & Jerry's Gifts")
___ American Express ___ Mastercard ___ Visa ___ Discover

Credit card #____________________________ & exp. date:____________


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