Juice Concentrate Fax Order Form

Fruit Juice Concentrate Fax Order Form

School:	Contact Person:
Address:	Phone:	( _ _ _ ) _ _ _ - _ _ _ _
City, State, Zip:	Order Date:

1 Case of Juice Concentrate Makes 22.5 Gallons of Juice!

Flavors can be mixed within the case, if desired. (6-1/2 gallon jugs of concentrate per case)

Flavors	Qty
Apple (Stain Fighter Flavor)
Berry (Stain Fighter Flavor)
Cherry (Stain Fighter Flavor)
Cran-Apple
Fruit Punch (Stain Fighter Flavor)
Orange Pineapple
Orange Raspberry
Peach (Stain Fighter Flavor)
Peach Mango
Strawberry Kiwi
Tangerine (Stain Fighter Flavor)
White Grape (Stain Fighter Flavor)
TOTAL JUGS (Total must be in multiples of 6.)

All juice products are 100% juice blends when reconstituted 1+6.5 with water

.____ Qty. of Mixing Pitchers Needed ($5.99 each)

Juice Concentrate: $96.00/cs (12+ jugs-Multiple Case Orders); $90.00/cs (6 jugs-Single Case Orders)

(Shipping & Handling Charges Extra & May Vary Depending Upon The Destination. Prices subject to change without notice.)

Please Check Preferred Payment Option:

1. ____ VISA / MASTERCARD

2. ____ Invoice Corp. Accts. Pay. (Net 15 with Pre-Approval)

Credit Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Exp. Date __ __ / __ __ / __ __

Name (exactly as it appears on the credit card) ____________________________________________

Credit Card Signature ______________________________________________________

"I hereby authorize and understand that my signature gives permission to West Coast Concessions, Inc. to charge the above credit card

account for the purchase and delivery of juice and/or other supplies indicated.”

Billing Address: Street or P.O. Box # __________________________________ City _____________ State ___ ___ Zip Code ____________________