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Dakota Care Packages Order Form - you may print
and use this form to mail or fax your order to us if you prefer.
Your
Name:______________________________________
Address:_________________________________________
City:_________________________State:_____Zip:_______
Your Daytime Phone
#:______________________________
___Check or Money Order Enclosed
___Please charge to my credit card ..___Visa
___MC ___Discover ___AE
Credit Card #____________________________ Expiration Date____________
Signature__________________________________________________
How would you like the card signed with your
package?
_____________________________________________________________________________
Ship to:
Name__________________________________________
Address________________________________________
City, State, Zip___________________________________
Phone #________________________________________
| Item # ____ |
Price_______ |
Shipping_______ |
Total_______ |
Ship to Arrive_______ |
Name__________________________________________
Address________________________________________
City, State, Zip___________________________________
Phone #________________________________________
| Item #____ |
Price_________ |
Shipping_______ |
Total_______ |
Ship to Arrive________ |
Name__________________________________________
Address________________________________________
City, State, Zip___________________________________
Phone__________________________________________
| Item #____ |
Price________ |
Shipping________ |
Total_______ |
Ship to Arrive_________ |
Clark Flower & Gift Shop
PO Box 214
Clark SD 57225-0214
Call toll free 1-800-658-3966 or fax 1-800-231-7312
email clarkflo@itctel.com
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