Refuge Farms Order Form PRINT OUT this form and send it along with
your check or money order directly to:


Refuge Farms, Inc.
Bonita Memory Bench
P.O. Box 195
Spring Valley, WI 54767
[PLEASE PRINT]
Order Date:  
Name:  
Street Address(1):  
Address(2):  
City:  
State:  
Zip Code:  
Telephone Number:  
Email Address:  
Order Description Quantity x Cost = Sub Total
1 - Bonita Memory Bench 1 x $50.00  = $50.00 
Shipping & Handling (included) [continental US only] $0.00 
DO NOT SEND CASH - Check or Money Order only. TOTAL ENCLOSED $50.00 
Please make check or money order payable to Refuge Farms, Inc.
Thank you for your order!
If this is a gift order, please fill in the information requested below:
Gift Given By:  
Recipient's Name:  
Street Address(1):  
Address(2):  
City:  
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