HIGHLAND BASKETS at THE COUNTRY GOOSE
115 MAIN STREET, COLD SPRING, NY 10516
PHONE: 845-265-2122 / FAX: 845-265-3445 / EMAIL: goose@highlands.com

 

DATE ORDERED: ________ COMPLETED: _______ SENT: ______ BILLED: ________

 

FROM: __________________________________________________

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TEL # __________________________

TO: ___________________________________________

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TEL # ___________________________

 
 
METHOD OF PAYMENT: MC ___ VISA ___ AMEX ___ DIS ___ CHECK ___ CASH ___
 
CREDIT CARD # _____________________________ EXPIRATION DATE: __________________  
OCCASION FOR GIFT:_____________________________________________________________
AMOUNT TO SEND: _____________ EXCLUDING TAX & SHIPPING ___________  
  INCLUDING TAX & SHIPPING ___________  
     
CONTAINER TYPE: BOWL ___ FLOWER POT ___ BAG ___ OTHER _______________________
 
DIETARY CONSIDERATIONS : ______________________________________________________
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MESSAGE: _______________________________________________________________________
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TOTAL BASKET:   $ _______________
UPS ZONE: ____________________ WEIGHT: _____________ $ _______________
  INSURANCE: $ _______________
  SALES TAX: $ _______________
  TOTAL: $ _______________