This page contains a Flash digital edition of a book.
Detach along perforated line.


334 West Stroud Street Ste 1 Randolph, WI 53956-1341


HPS CATALOG #


(If pre-printed name and address is incorrect, write correct information below. If not pre-printed, attach peel-off label from back cover in blank area above.)


FIRM OR INDIVIDUAL ________________________________________________ ADDRESS __________________________________________________________ CITY___________________________________ STATE ______ ZIP____________ DAYTIME PHONE (____)_______________________________________________


EMAIL ADDRESS _____________________________________________________ Q For shipping confirmation via e-mail, please provide your e-mail address. Q


Payment methods: (Please do noT send cash) ❑ Check or Money Order ❑ Charge to Account*


❑ VISA ❑ MasterCard ❑ DISCOVER


Account # _______________________ ❑ AMERICAN EXPRESS *Charge Orders accepted only if credit has been previously approved by our HPS Grower Division. If not previously approved, send payment with order to avoid any delay.


Credit Card No. _______________________________________________________


_______________________________ ________ Signature of Card Holder


Expiration date Credit Card will be charged when order is placed IMPORTANT NOTICE!! CHECK ACCEPTANCE POLICY


If you pay by check and your check is returned to us, it will be represented electronically and your account will be debited for the amount of the check plus a fee of $35.


Ship To: Use Space below ONLY if different from above Name _____________________________________________________________________ Address ____________________________________________________________________ City ________________________________________________ State _____ Zip _______


CATALOG #


15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37


BALANCE TO CARRY TO NEXT COLUMN ➞ Detach along perforated line. PG. # CODE QTY SIZE NAME OF ITEM WANTED Substitution Service


If we run out of an item, may we substitute a similar variety of equal or greater value?


❑ Yes ❑ No Our Mailing List


❑ We occasionally make our mailing list available to carefully screened companies we think may be of interest to you. If you prefer we do not include your name please check this box.


PRICE CATALOG #


38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59


TOTAL SIDE TWO ➞ PG. # CODE QTY SIZE


TOTAL THIS PAGE TOTAL REVERSE SIDE MERCHANDISE TOTAL MINIMUM SERVICE & HANDLING CHARGE PER ORDER


WI ORDERS ADD 5% SALES TAX PLUS APPLICABLE SALES TAX FOR YOUR COUNTY


TOTAL AMOUNT ENCLOSED (Make check or Money order payable to hpS Grower diviSion)


1 2 3 4 5 6 7 8 9


10 11 12 13 14


PG. # CODE QTY SIZE FOR OFFICE USE ONLY


Date ___________ Init _________ CK _________________________ CA _________________________ CR _________________________


G ___________________________ T ___________________________ CID _________________________ O# __________________________


USE THIS ORDER FORM


IF YOU ARE NOT ORDERING PIXIE® STAKES


NAME OF ITEM WANTED


Phone Toll-Free 1-800-322-7288... or Fax Toll-Free 1-888-HPS SEED... or visit our website: www.hpsseed.com


PRICE


$8.95


BALANCE FROM PREVIOUS COLUMN NAME OF ITEM WANTED


➞ PRICE


131 1/10/12 3:01 PM


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