Ashley Food Co., Inc

P.O. Box 912

Sudbury, MA 01776

Tel: 978-579-8988

Fax: 978-579-8989

E-Mail: maddog@ashleyfood.com

Please fill out this form and fax or mail in for processing. Check, Credit Card Or Money Order

Type of Credit Card -- Amex – Discover Card -- Master Card – Visa

Bill To: Delivery To:

Name _____________________ Name ________________________

Street Address _____________________ Street Address________________________

Apt. _____________________ Apt. ________________________

City or Town _____________________ City or Town ________________________

State _____________________ State ________________________

Zip Code _____________________ Zip Code ________________________

Phone # _____________________ Phone # ________________________

E-mail Address _____________________ E-mail Address________________________

Signature _____________________ Order Date________________

Credit Card # ____-____-____-____-______ Exp Date _____________

Item			Price	QTY
			Sub Total
Shipping Charges List Below are for Lower 48 States USA Only			UPS Charge
			Order Total
Order Total		UPS Charge Chart
$10.00 to	$20.00	$12.00
$21.00 to	$40.00	$14.00
$41.00 to	$60.00	$16.00
$61.00 to	$80.00	$18.00
$81.00 to	$100.00	$20.00
$100.00 to	$150.00	$22.00