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Simon Order Form Name _______________________________________________________________________ Address _____________________________________________________________________ City ______________________________________________ State ______ Zip ___________ Telephone ________________________________________ Credit Card # _________________________________________ Exp. date ____________ Name on Card _______________________________3 digit validation code (back of card) _______
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Qty or lbs. _________ _________ _________ _________ _________ _________ _________ _________ _________ _________
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Flavor or name of item ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
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Total ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________
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Bulk candies must be ordered in 1 pound increments, with a minimum of 5 lbs total. To order by phone, please call 800-367-2441 or fax order to 717-367-4055
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