Kohl's Frozen Custard & Jumbo Burgers, Inc.®

OUR CUSTARD SHIPPING HOTLINE IS 910-350-0051
You may use this number to call or fax this form.

ORDER PLACEMENT

THERE ARE 3 WAYS TO PLACE YOUR ORDER;
1) Fax your order using BOTH PAGES of this form. Fax it to 910-350-0051.
2) Go to our web site at www.kohls-frozencustard.com and click on the Custard Shipping link.
3) Place your order over the phone, call 910-350-0051

If you are calling in your order, use this form to be sure you have all the information you need.

STEP 1 - Decide which method you will use to place your order (the methods are listed above).

STEP 2 - Complete this order form.

STEP 3 - Figure out your total cost, including shipping, using the information below, then fax or call us.

--- PICK A TOTAL OF 4 QUARTS & 2 PINTS - YOUR COST IS $75.00 + SHIPPING ---

Circle "P" (for Pint) or "Q" (for Quart)  next to the flavors you choose.

P  Q   1 CLASSIC VANILLA
	
P  Q   2 CLASSIC CHOCOLATE

P  Q   3 ALMOND JOY

P  Q   4 BANANA WALNUT CHOCOLATE CHUNK

P  Q   5 BUTTER PECAN

P  Q   6 CHERRY AMARETTO CHEESECAKE

P  Q   7 CHOCOLATE CHIP

P  Q   8 CHOCOLATE PEANUT BUTTER CHOCOLATE

P  Q   9 COOKIES 'N' CREAM

P  Q  10 DEATH BY CHOCOLATE

P  Q  11 DRUMSTICK

P  Q  12 ELEPHANT STOMP

P  Q  13 FRENCH KISS

P  Q  14 HEATH BAR

P  Q  15 HEAVENLY HASH

P  Q  16 MINT CHOCOLATE CHIP

P  Q  17 MOCHA MUD PIE

P  Q  18 MOOSE TRACKS

P  Q  19 PISTACHIO NUT

P  Q  20 SLOBBERKNOCKER

P  Q  21 TURTLE CHEESECAKE

P  Q  22 TURTLE SWIRL


Email address _____________________________________

SHIP TO ADDRESS INFO

NAME ______________________________________________
	
Address 1 _________________________________________

Address 2 _________________________________________

City, State, Zip __________________________________, ______  _____________

PHONE _____________________________________________


SHIPPING

Place an "X" next to the appropriate service. *SEE PAGE 2 FOR SHIPPING COSTS

_____ 2nd DAY	____ NEXT DAY

For the EASTERN portion of the USA (AL, CT, DE, DC, FL, GA, KY, ME, MD, MA, MI,
MS, NH, NJ, NY, NC, OH, PA, RI, SC, TN, VT, WV, WI)					
	NEXT DAY =$72.00	2ND DAY =$37.00
					
For the CENTRAL portion of the USA (AR, IL, IN, IA, KS, LA, MN, MI, NE, ND, OK, SD, TX)					
	NEXT DAY =$77.00	2ND DAY =$50.00
					
For the WESTERN portion of the USA (AZ, CA, CO, ID, MT, NV, NM, OR, UT, WA, WY)					
	NEXT DAY =$82.00	2ND DAY =$55.00


CREDIT CARD 

(Circle one)   VISA    MASTER CHARGE    DISCOVER    AMEX					

Name as it appears on card

____________________________________________________

Address listed with credit card company (if different than above)

____________________________________________________

Address 2						

____________________________________________________
City, State, Zip						

____________________________________________________, _________   _______________

Card Number

____________________________________________________						


_____  _____  _____
Expiration Date						
								
CHECK or MONEY ORDER**						
Make checks out to:	Kohl's Frozen Custard & Jumbo Burgers					
Address:	925 S. Kerr Ave., Wilmington, NC 28403					
**If paying by check, the check must clear before we can ship your order.

THANK YOU FOR YOUR ORDER!