Blue Haze Farm - Holly Order Form
Print this blank form, fill it out in black pen or dark pencil, 
then fax toll-free to: 1-888-258-4213
(in Victoria BC fax to: 474-4577)

or send information by phone or e-mail.

Your name: ______________________________________________

E-mail Address: _________________________________________

Billing Address: ________________________________________

Street: _________________________________________________

City: ___________________________________________________

State/Province: _________________________________________

Zip/Postal Code: ________________________________________

Telephone: (_____) ______________________________________

Fax:       (_____) ______________________________________

Special Instructions: 
(we try to oblige) ______________________________________


Payment by: (Please check one):
___ Cheque (Send by mail)

___ VISA (Fill out:)


Card Number: ____________________________________________

Name on Card: ___________________________________________

Expiry: _________________________________________________


Shipping Address:
Name: ___________________________________________________

Street: _________________________________________________

City: ___________________________________________________

State/Province: _________________________________________

Zip/Postal Code: ________________________________________

Telephone: (_____) ______________________________________

Gift Message: ___________________________________________

_________________________________________________________

_________________________________________________________

Add additional addresses, giving above information: