ORDER FORM  (Print)

Personal Information
      Name:  ______________________________            Mailing Address:  __________________________________
      Phone #: __________________                                 ________________________________________________

Payment Information

       Name on Card:  _______________________        Credit Card :  _________________________
       Experation Date:  ____________                            Credit Card Type:  ___Mastercard  ___Visa


Shipping Information
(If different from above)

         Name:  _______________________________            Mailing Address: ______________________________________   
                                                                                      ___________________________________________

Items Ordering

ITEMS                                                                    QTY          X             PRICE             =                TOTAL

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​                 Sub Total                                                                                                                                                                _______________
                 Sales Tax 8.5% (Louisiana Only)                                                                                                                               _______________
                 Shipping & Handling
                     --Rice Steamer shipping charge is $15.00 first one and $5.00 each additional one                                                                          
                     --All other items shipping charge is $5.00 for every $25.00 spent                                                                              _______________
                 TOTAL                                                                                                                                                                                    ________________

  Phone, Fax, or Mail in Your Order Form
P.O. Box 1425, Crowley, LA  70527-1425
Phone: 337-783-6417 / Fax:  337-250- 4704