Coffee Fundraiser for Bridge to Reading

Authentic Cuban Coffee Order Form

Name

*

Email

*

This address will receive a confirmation email

Phone

*

What kind of Roast would you like?

*

Please select all that apply.

Espresso Light Roast Dark Roast Decaf

How would you like your beans?

*

Please select all that apply.

Ground Whole

Explain choices, if there are multiple Roasts/Beans...

$12.50 per 1lb. Bag

1 ($12.50) 2 ($25) 3 ($37.50) Buy 4 get 5th Free ($50) 6 ($62.50) 7 ($75) 8 ($87.50) Buy 9 get 10th free ($100) I will pay by check ($0)

Amount

Payment...if you'd like to pay by check, please make check out to "N3C" and put "B2R" in Memo section

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Authentic Cuban Coffee Order Form

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