PRINT OUT this form and send it along with your check or money order directly to: Refuge Farms, Inc. Hannah 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 - Hannah 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:
State:
Zip Code:
Message: