Lodi Coffee Roasters' Order Form
| Print out and complete this form. Your order and payment may be mailed in, phoned in or faxed in. Once we have your payment/credit card information, you may also arrange to email your order. Shipping and handling costs for the first bag of coffee is $5.95. Add just $1.00 to the shipping and handling total for every additional bag. (Example: 3 bags of coffee would be $7.95 shipping and handling). Your order will usually be shipped within a day or two from our roastery. |
| Customer Information |
|---|
| Name __________________________________ Phone _________________________ |
| Address __________________________________________________________________ |
| City ____________________________ State _____ Country _______ Zip Code ________ |
| Email Address (optional) _______________________________________ |
| Check/Money Order ___ Visa ___ Mastercard ___ |
| Credit Card Number ________________________________________________________ |
| Expiration Date ________________ Authorization Number _______________________ |
| Name As It Appears On Card ________________________________________________ |
| Signature As It Appears On Card _____________________________________________ |
| Please complete if Shipping Address is Different than Customer Address: |
|---|
| Name __________________________________ Phone _________________________ |
| Address __________________________________________________________________ |
| City ____________________________ State _____ Country _______ Zip Code ________ |
| Email Address (optional) ______________________________________ |
| Quantity | Item No | Item Description | Unit Price | Subtotal |
|---|---|---|---|---|
| ______ | GIbR12 | Gibraltar's Rock Blend - 12 Oz. | $ 7.50 | ____________ |
| ______ | GIbR16 | Gibraltar's Rock Blend - 1 Lb. | $ 9.50 | ____________ |
| ______ | SUM12 | Sumatra Mandehling, Grade 1 - 12 Oz. | $ 8.00 | ____________ |
| ______ | SUM16-L | Sumatra Mandehling, Grade 1 - 1 Lb. | $ 10.00 | ____________ |
| ______ | FC12 | Ferry Crossing Breakfast Blend - 12 Oz. | $ 7.00 | ____________ |
| ______ | FC16 | Ferry Crossing Breakfast Blend - 1 Lb. | $ 9.00 | ____________ |
| ______ | GUAT12 | Guatemalan Huehuetenango Dark Roast - 12 Oz. | $ 7.00 | ____________ |
| ______ | GUAT16 | Guatemalan Huehuetenango Dark Roast - 1 Lb. | $ 9.00 | ____________ |
| ______ | Tanz12 | Tanzania Peaberry - 12 Oz. | $ 7.50 | ____________ |
| ______ | Tanz16 | Tanzania Peaberry - 1 Lb. | $ 9.50 | ____________ |
| ______ | MEX12 | Mexican Altura - 12 Oz. | $ 7.00 | ____________ |
| ______ | MEX16 | Mexican Altura - 1 Lb. | $ 9.00 | ____________ |
| ______ | ETHIOP12 | Ethiopian Harar "Horse" - 12 Oz. | $ 7.50 | ____________ |
| ______ | ETHIOP16 | Ethiopian Harar "Horse" - 1 Lb. | $ 9.50 | ____________ |
| ______ | COS12 | Costa Rican- 12 Oz. | $ 7.00 | ____________ |
| ______ | COS16 | Costa Rican- 1 Lb. | $ 9.00 | ____________ |
| ______ | FRENCH12 | Classic French Roast- 12 Oz. | $ 7.50 | ____________ |
| ______ | FRENCH16 | Classic French Roast - 1 Lb. | $ 9.50 | ____________ |
| ______ | DECAF12 | Duck's Decaf - 12 Oz. | $ 7.50 | ____________ |
| ______ | DECAF16 | Duck's Decaf - 1 Lb. | $ 9.50 | ____________ |
| Order Subtotal | $ ___________ | |||
| Specify Ground or Whole Bean:___________ | *no charge* | |||
| Shipping and Handling ($5.95 for first bag of coffee; $1.00 for each additional bag) | $ ___________ | |||
| Order Total | $ ___________ | |||