Melli Chocolates LLC Order Form
  PO Box 316 Cambridge, WI  53523
Phone Toll Free (866)423-9662  ~ Fax (866) 423-9662

Billing To:
First Name        Last        
Address           
Address          
City        State       Zip      
Phone (day)       Fax       
E-Mail       
Ship To (if different from above) or Gift Recipient:
First Name       Last       
Address     
Address      
City       State       Zip      
Purchases:
Qty Description - please note milk, dark, white, or assorted. Size Gift Box Unit Price Total Price

$

$

                $  
        $ $
        $ $
        $ $
                $  
              $ $   
Merchandise Total $
Gift Box Charge ($.50 each) $
Order by Telephone - 866-423-9662    if no answer please leave message and number Subtotal $ 
Fax your credit card order 24 hours a day, 7 days a week.                        WI residents add 5.5% $

Payment Method please enclose check / money order  OR    

Shipping Charge 
$7.50 per box
$
Visa   MasterCard  Discover  AMEX               Total $
Exp.Date__ __/__ __/ __ __           CID # (last 3 on back) __/__/__
No.____________________________________                

Signature (as shown on card):                                                   Print: