Nut Order Form

Maple Street Chapel Preservation Society

Nuts for the 2011 Holiday Season

Order Form

Print this form.

Enclose check payable to Maple Street Chapel.

Mail to:
Tom Scott
2S 474 Beechwood Ln
Glen Ellyn, IL 60137

Orders must be submitted by Sunday, October 30th.
They should be picked up at First Church of Lombard on Sunday, November 20th.

Name

E-mail address

Phone

Product Number	Item	Price Each	Quantity	Total Cost
60000	Pecan Halves, Fancy Mammoth Natural	$10.00
60010	Pecan Pieces, Fancy	$10.00
60015	Walnut Halves - Large and Pieces	$9.00
60025	Mixed Nuts Deluxe (no peanuts)	$9.00
60064	Peanuts - Honey Roasted	$5.00
60070	Cashews - Honey Roasted	$9.00
60081	S'mores Mix	$6.00
60087	Sweet & Salty Trail Mix	$6.00
62010	Chocolate Coated Jumbo Raisins	$6.00
62022	Chocolate Coated Peanuts	$6.00
	Payable by check to Maple St. Chapel		Order Total

If paying by credit card (Visa or MasterCard only), give the following information:

O Visa
O MasterCard

Account Number                                                 3-char code on back of card


Name as appears on card                                               Expiration date


Signature