Date_____________ (for office use)
Return Form to:

The Herb Cottage
442 CR 233
Hallettsville, TX 77964-4808
Phone and Fax (979)562-2153
e-mail: cindy@theherbcottage.com
Bill To:
*Name: ________________________________
*Address: _______________________________
*City: ______________________ State: ______ Zip: _________
*Phone: _____________ *e-mail: ______________________
*Required fields for order to be filled. 		Ship To, if different than Billing Address:
*Name: ________________________________
*Address: _______________________________
*City: ______________________ State: ______ Zip: ____________
*Phone: _____________ *e-mail: ______________________
*Required fields for order to be filled.



NAME OF ITEM QTY. $ EACH $ TOTAL
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
______________________________ ___________ $_________ $_________
Shipping Charges $1.50
Subtotal $_________

Tax ( TX Residents Only) 8.25% $_________

TOTAL $_____________



METHOD OF PAYMENT: VISA:_____ M/C:_____ Amex: _____ Discover: _____ Check, money order: _____

Credit Card Number: ________________________________________________________

Expiration Date: _____________ CSV Number: _____________ (This is the 3-digit number on the back of your card near or in the signature space.)

Signature: ____________________________________________________________________