Complete this form and a Bucky Cheese represenatative will contact you to complete your order.

Please provide the following contact information:

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone
E-mail

Please provide the following ordering information:

QTY	DESCRIPTION		COST	TOTAL
	BUCKY CHEESE
	Go For Two Gift Box		$17.00
	Wisconsin Six Pack		$32.00
-----------	---------------------------------	-------	--------------	------------
	Bucky Cheese Total
	Bucky Cheese Shipping		See Chart
-----------	---------------------------------	-------	--------------	------------
	Total For Order

	BILLING
Credit Card or Check Number
Expiration Date
Type

	SHIPPING
Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country