The Navajo Co-op Telephone an Order: 1-505-862-8075
P.O. Box 838 Fax an Order: 1-505-862-8809
Thoreau, NM 87323 E-mail: gathplac@cia-g.com
Ship to: ___________________________________________________________
Street Address: ____________________________________________________
City: ______________________________State: ______ Zip: _____________
Phone: ____________________ E-mail: ________________________________
ORDERED BY: SHIP TO:
Name _____________________________ Name __________________________
Address __________________________ Address _______________________
_____________________________ __________________________
City _____________________________ City __________________________
State ______ Zip Code ___________ State ______ Zip Code ________
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Item # | Qty | Description | Price Ea. | Total
=====================================================================
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
_______ ____ _________________________________ $________ $_______
Subtotal $_________
Shipping & Handling $_________
Value of Shipping &
Order Handling Cost NM Residents Add 5.6% $_________
Up to $ 25 $ 3.50
$25 - $ 75 $ 6.60 Donations to
$75 - $150 $ 8.50 The Gathering Place $_________
Over $150 $10.00
GRAND TOTAL $_________
METHOD OF PAYMENT:
_____Check or Money Order _____MasterCard _____Visa
Card Number: _______________________________________________________
Expiration Date: ________________
Signature: _________________________________________________________
Last Updated January 16, 1999