PRINT OUT this form and send it along with your check or money order directly to: Refuge Farms, Inc. Jerry, Retired 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
11" x 17" Jerry, Retired signed print (unmatted, printed on heavy card stock)		x	$35.00	=	$
Shipping & Handling (included) [continental US only]					$0.00
DO NOT SEND CASH - Check or Money Order only. TOTAL ENCLOSED					$
Please make check or money order payable to Refuge Farms, Inc.

*** Please allow 1-2 weeks for delivery of merchandise ***   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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Message: