Order Form

Your Guide to www.mrsmyers.com


How to get a hold of us and how to order.

Just fill out the order form below and then press the button at the end of the form marked Send Order.

If you prefer you may call us, fax us or mail us, at the following locations:
Phone:(800)555-1234
Fax:(916)265-3198
US Mail:Mrs. Myers Chocolates
1 Walnut Street
Evansville, IN 60098
Press here for Shipping charges.

Please complete a separate order form for each address receiving an order

ORDER DATE:

Bill To:Ship To:
NAME:
COMPANY:
ADDRESS:
CITY, ST:,,
ZIPCODE:
YOUR EMAIL: YOUR PHONE:
METHOD OF PAYMENT:
Since this is not a secure site entering your credit card number is optional. You may FAX your card number or call our telephone number (800)555-1234 with that information if you are concerned about online security.
CARD #: EXP. DATE:


Please indicate type of chocolate for each item; Light, all Dark or Mix. All of our products can be made with Dark, Milk, or White chocolate.
BOXED CHOCOLATES
ItemQty.TypeChocolateWeight
1.
2.
3.
GIFT PACKS
ItemQty.Code ChocolateWeight
1.
2.
3.
SUGAR FREE CANDIES & TAFFIES
ItemQty.CandyWeight
1.
2.
3.

GIFT WRAPPED? YES -- NO

GIFT CARD TO READ:


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