First Name:
Last Name:
Address 1:
Address 2:
City: State: Zip Code:
Credit Card Number: (Ex: 1234-5678-1234-5678) _________-_________-_________-_________
(NOTE:  If this is a mail order, you may also pay by money order or certified check in US funds)
Type of card:   ____Visa  ____Master Card  ____Discover    Expiration Date: ______/______
Name as it appears on card:
Your signature: __________________________________________________________
Item No. Product Name & Brand Product
Size		 Number
Ordered		 Price
Per Item		 Total
           
           
           
           
           
           
           
           
           
           
           

 
Thank you for ordering from the Health Food Store and Klassic Kitchen Korner!
118 E. Kemp Ave.
Watertown, SD 57201
PHONE: 1-800-319-7675 or 605-886-4626
FAX: 605-882-0756
healthfoodcenter@yahoo.com