2009 De Bruyn Seed Store Mail Or Fax Order Form

Name: ____________________________________________ Address: ________________________________________
City, State, Zip: ________________________________________ Daytime phone: ____________________________________
Method of Payment: Check: ____Visa:____  MasterCard: _____ C.O.D. _____ Credit Card Number: ________________________________
Expiration Date: _______                                  3 Digit Code:_______ (found on back of card) Signature: _________________________________________
Name & Description of Seed Quantity Unit Price Price
       
       
       
       
       
       
       
       
       
       
Total from this side:  
Total of other side:  
SUBTOTAL:  
MI Residents add 6% sales tax  
Shipping & Handling: (from e-mail)  
C.O.D. Charges ($10.00)  
TOTAL:
Shipping Charges: Under 1 lb. Add $5.80
  1 lb to 5 lb. Add $10.80
Shipping outside the continental US: Please contact us for the shipping prices. Please e-mail or call me for the shipping prices at debruynseed@att.net or 616-772-2316 Thank you. Jan

If you need more room, just use the back side of this form once it is printed.

Remember: Michigan residents must add 6% state sales tax

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DE BRUYN SEED STORE      101 EAST WASHINGTON        ZEELAND, MICHIGAN    49464                                       616-772-2316    FAX 616-772-0011    debruynseed@att.net