High Country Roses	Printable Order Form
9122 East Highway 40, PO Box 148 Jensen, Utah 84035-0148 Phone (435) 789-5512 or (800) 552-2082 Fax: (435) 789-5517, E-mail: roses@easilink.com	Order Date: _______________________ Please indicate preferred ship date: Week of _________________________

SOLD TO:		SHIP TO: (if different address):
Name		Name
Address		Address
City		City
State, Zip		State, Zip
Phone		Delivery Phone
Fax / E-Mail		Check here if gift and include message below: _____

Qty.	Variety	Each	Total

For roses not in stock: Refund Substitute (please list above) Method of Payment: Check or Money Order enclosed,        payable to High Country Roses Credit Card (billed at time of shipping) MasterCard Visa Discover Card # __________-__________-__________-__________ Exp. Date _______/_______ Signature _______________________________________ Credit Card Billing Address & Zip (if different than "sold to") _______________________________________________	Subtotal for _________ roses:
	Shipping to Utah : add 6.5 % Sales Tax
	Shipping & Handling for 1 or 2 roses to shipping regions A, B & C: Please see chart for shipping code.	$8 .00
	Add $1.00 for each additional rose after the first two:
	If shipping to states in region B, add $4.95          or If shipping to states in region C, add $7.95
	TOTAL AMOUNT DUE:

           

SHIPPING REGIONS
A	B	C
AZ, CA, CO, ID, KS, MT, ND, NE, NM, NV, OK, OR, SD, UT, WA, WY	AL, AR, IA, IL, IN, KY, LA, MI, MN, MO, MS, OH, TN, TX, WI	AE, AK, CT, DC, DE, FL, GA, HI, MA, MD, ME, NC, NH, NJ, NY, PA, PR, RI, SC, VA, VI, VT, WV