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Michigan Gold: Syrup Order Form.

Item Name & Description

 Price Quantity Total
Plastic Bottles
One Gallon $42.00
Half Gallon $23.00
One Quart $14.00
One Pint $8.00
Half Pint $5.00
Glass Maple Leaf
50ml $3.50
250ml Plain $8.00
250ml Michigan etch $12.00
250ml Fall Leaves $12.00
200ml 3D Black Painted $12.00
250ml Round Bear $10.00
250ml Round Deer $10.00
Cherry Syrup 12 oz. $4.95    
Product Subtotal
Delivery Charge
Total Charge
ODERED BY: SHIP TO:
Name:

 Name:
Address:

 Address:
City/State/Zip:

 City/State/Zip
Daytime Phone: Daytime Phone:
Gift Card Message:

Delivery Rates
You may figure out your shipping or just send us your order and we will bill you.
Shipping is per address
$0 to
$10		 $10.01 to
$25		 $25.01 to
$40		 $40.01 to
$70		 $70.01 to
$100		 $100.01 to
$150

Area 1

 MI, WI $5.50 $6.50 $7.50 $9.00 $10.25 $12.00
Area 2 DE, DC, IL, IN, IA, KY, MN, OH, PA, WV $6.00 $7.25 $8.50 $10.25 $13.50 $15.50
Area 3 AL, AZ, AR, CO, CT, FL, GA, KS, LA, ME, MD, MA, MS, MO, MT, NE, NH, NJ, NY, NC, ND, OK, RI, SC, SD, TN, VT, VA, WY $7.00 $8.25 $9.75 $13.00 $19.00 $23.50
Area 4 CA, ID, NV, NM, OR, TX, UT, WA $7.50 $9.00 $11.00 $18.00 $25.50 $33.50

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Tom Casier • 4288 Ridgemoor - Traverse City, MI 49684 • Phone(Office): 231.995.9336