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PLEASE PRINT THIS ORDER FORM, COMPLETE, AND MAIL
The Azalea Patch, 2010 Mountain Rd., Joppa, MD 21085 | phone: 410.939.3871
Name
Address
City
State
Zip
Phone
Email
Shipping Date
We ship by USPS Priority Mail - $30 minimum order
May We Subsitute? Yes
No
click here for shipping charges
METHOD OF PAYMENT
Check Enclosed
Charge My Credit Card
Visa
Mastercard
Discover -- Expiration ___________
Card Number:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Signature: ___________________________________________
QTY
CULTIVAR
PRICE
QTY
CULTIVAR
PRICE
1
.
.
.
.
12
.
.
.
.
2
.
.
.
.
13
.
.
.
.
3
.
.
.
.
14
.
.
.
.
4
.
.
.
.
15
.
.
.
.
5
.
.
.
.
16
.
.
.
.
6
.
.
.
.
17
.
.
.
.
7
.
.
.
.
18
.
.
.
.
8
.
.
.
.
19
.
.
.
.
9
.
.
.
.
20
.
.
.
.
10
.
.
.
.
21
.
.
.
.
11
.
.
.
..
.
.
.
.
22
.
.
.
.
.
.
.
.
Gift Certificate Amount
.
Sub-Total
.
15 % East of Mississippi River | 20 % West of Mississippi River -- Postage
5% sales tax for MD residents
.
TOTAL
.
