"Goodies From Home"
Order Form

Please fill out the following information:

LAST NAME . . . FIRST NAME

Street Address or Box #

City . . . . . . . State . . . . . .Zip Code

Phone Number --

E-mail Address

Bank Name Bank City Bank State

Fraction Code at the Top Right of the Check (Example 5 - 215/1011)
(NOTE: Your check may NOT have a Fraction Code-If it doesn't, leave this BLANK)

Check Number Routing Number Acct. Number

Total sequence at bottom of check from left to right:

Use /: for transit symbol /' for ON US symbol and /// 
for the 
Symbol 
Enter Bottom of Check As Above      

LAST NAME: ...FIRST NAME:

** NOTE: UPS will NOT deliver to a P.O.Box. MUST have dorm/physical address **
Street Address or Box #

CITY STATE ZIP CODE

PHONE NUMBER --

E-MAIL

BIRTH DATE GRADUATING YEAR SEX

PACKAGE # PACKAGE DESCRIPTION

Choices (if applies)

PACKAGE PRICE $
LOCAL TAX $ (NY DELIVERIES ONLY)
SHIPPING $ (SEE BELOW)
SPECIAL HANDLING $ (SEE BELOW)
-----------------------------------------------
TOTAL CHECK AMOUNT: $

**** FREE GIFT WITH ALL ORDERS PLACED BY SEPTEMBER 30, 1997 ****

By submitting this form you authorize "Goodies From Home", West Babylon, NY, to draft a check on your bank account for the amount shown below. You will receive a copy of the check in your next monthly bank statement and your order will be shipped within two weeks (usually 48 hrs.), after your check clears. A $20.00 fee will be charged for returned checks.

Shipping Fees:
Up to $30: $5.95
$31 - $60: $8.95
$61 - $90: $11.95
Over $91 $17.95

Special Handling Fees:
Two Day Air: $13.50
Overnight: $25.50