Print this form & mail or fax.  You may pay by check.  You may include 
your personal/business cards.  You do not have to send this specific form, 
You can type or write your own list and mail or fax.....but please include all of the
following info if you write or type your order. 

YOUR Contact Information

Email (if available)_____________________________________________________________________________

Name_________________________________________________________________________________________

Company_____________________________________________________________________________________

YOUR Billing Address (where credit card is mailed)________________________________________________

City-State-Zip__________________________________________________________________________________

Phone (h)__________________________________Phone (w)________________________________

Will you be sending us your own business/personal cards to enclose    yes / no

Payment   -  check____money order_____    Visa  MC  Discover  Other

Credit card #_______________________________________________________Exp______________________

Name on card____________________________________________________Security Code_______________

ITEM to Send_________________________Deliver the week of______________________________

Special Note_________________________________________________________________________________
..................................................................................................................................................................
SHIP TO  (Be sure to include the following info for each additional gift)

Gift Card Message___________________________________________________________

Gift Card Signature___________________________________________________________________________

Name_______________________________________________________________________________________

Company____________________________________________________________________________________

Address_____________________________________________________________________________________

City State Zip________________________________________________________________________________

For additional gifts, type or write names, choose gift & email, mail or fax to us.
Toll Free Phone -  888-973-2267      Baton Rouge area - 225-627-6852      Fax -  225-383-2832      
Mail -  Pointe Coupee Pecan  PO Box 10  Glynn, LA 70736......... since 1990