Order Form

Please provide us with the following information. All fields are required.

Personal information

 First Name:

Last name:

Street Address:

City:

Phone Number:

Email Address:

Product Selection

 Tomatoes: $2.50/lb
Quantity

Potatoes: $0.30/lb
Quantity

Pumpkin Pies: $2.00/pie
Quantity

Organic Broccoli: $2.00/lb
Quantity

Organic Carrot: $2.00/bag
Quantity

Long Seedless Cucumber: $1.10/each
Quantity

Garlic: $3.00/pound
Quantity

Red Onion: $0.50/pound
Quantity

Payment Information

 Full Name on Credit Card:

Billing Address:

Credit Card Number:

Expiration Date:

Security Code: