Customer Information: (please print)

Name:

Address:

City/State/Zip:

Phone:

Ship To: (if different from above address)

Name:

Address:

City/State/Zip:

Method of Payment:

Check (payable to "Orchard House")   
MC       VISA       AMEX       __ Discover      __ Diners Club

Card Number:   Expiration Date: 

Order Information:

Quantity

Item

Size/Color

Price