RARE PLANT RESEARCH
13245 S.E. Harold
Portland, Oregon, USA, 97236
FAX (503) 762-0289
e-mail: rareplantr@aol.com
Print this form if you are going to Fax or mail your order.
Ordered By:

Name_____________________________________________________ Date:_____________________

Address_____________________________________________________________________________

City ______________________State _______________Zip_________________Country ____________

Phone (____ )________________________________Fax (____ )______________________________

E-Mail _________________________________________

Quantity
Description
Size
Item
Price
Total
Price
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
Sub Total $
National Shipping - 15% of Sub Total $
International Shipping - 30% of Sub Total $
CITES Documentation - $30.00 $
Phytosanitary Certificate - $15.00 $
Total $
PAYMENT WILL BE BY: (Please circle one of the following)

CHECK - MONEY ORDER - VISA - MASTERCARD

Credit Card Number____________________________________Expiration Date_________________

Signature _______________________________________________

NOTE: It is NOT SAFE to send credit card information via e-mail.
Please list Preferred Sustitutes

Quantity
Description
Size
Item
Price
Total
Price
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
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. . . $ $
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