Jam Order Form

Thornton W. Burgess Society

Green Briar Jam Kitchen

Order Form

Quantity	Item(s)	Price Each	Total






	SUB-TOTAL
	SHIPPING & HANDLING (from chart)
	TOTAL AMOUNT DUE

Payment Method
No COD’s - US Funds

Please make check or money order payable to:
Thornton W. Burgess Society
Mail to: Green Briar Jam Kitchen
6 Discovery Hill Road
East Sandwich, MA 02537
Phone order to: (508) 888-6870
Fax: (508) 888-1919

Charge to my credit card __ VISA __ MasterCard

Number: ____________________________________

Expiration Date: ____________

Signature: ___________________________________

Ordered By	Ship to
Email:
Phone No.
Name	Name
Address	Address
City, State, Zip	City, State, Zip