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Print this form then: Fax or Mail Your Order   fax:1-630-898-6445   Date: ______________________ Name: ____________________________________________________________ Address: ____________________________________________________________   ___________________________________     City: ___________________________________ State: ___________________ Phone: ___________________________________ Zip: ___________________     Shipping address if other than above:   (P.O. Box Holders - Provide street address) Name: ____________________________________________________________ Address: ____________________________________________________________   ___________________________________     City: ___________________________________ State: ___________________     Zip: ___________________ Charge Card Information:              ____Visa        ____Mastercard       ___American Express Number: _________________________________________________________________________ Expires: _________________________________________________________________________ Print Cardholder Name  ____________________________________________________________ Cardholder Signature ______________________________________________________________ _____________________________________________________________________ Qty Size Whole Bean or Ground Regular or Decaf Item - Name/Description Total ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ ________________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ ____ ____ _______ _______ _______________________________________ ____________ World Class Coffee sub total: ____________ P. O. Box 167 IL sales tax (7.5%): ____________ Geneva, IL 60134 Shipping and Handling: ____________ Local 630-898-6908  Toll Free 877-898-6908     Thank You For Your Order TOTAL: ____________

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