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style='width:465.0pt;mso-cellspacing:0in;mso-yfti-tbllook:1184;mso-padding-alt: 0in 0in 0in 0in'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;height:1.5in'> <td valign=top style='padding:0in 0in 0in 0in;height:1.5in'> <p class=MsoNormal align=center style='text-align:center'><span style='mso-fareast-font-family:"Times New Roman";mso-no-proof:yes'><img width=340 height=258 id="_x0000_i1061" src="images/logo-no-bg.png"></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td valign=top style='padding:0in 0in 0in 0in' background="images/bg-gold.jpg"> <form id="FrontPage_Form1" onSubmit="return FrontPage_Form1_Validator(this)" language=JavaScript> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><span style='display:none;mso-hide:all'><INPUT TYPE="hidden" NAME="sendmail" VALUE="Email from CostonFarm.com"><!-- Change the following value to your EMail address 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class=MsoNormal align=center style='text-align:center'><span style='mso-fareast-font-family:"Times New Roman"'>Gift Box Order Form<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;height:23.25pt'> <td width="140" valign=top style='width:26.0%;padding:0in 0in 0in 0in; height:23.25pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>NAME ON CREDIT CARD:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td width="2%" valign=top style='width:2.0%;padding:0in 0in 0in 0in; height:23.25pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='width:72.0%;padding:0in 0in 0in 0in; height:23.25pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><!--webbot bot="Validation" b-value-required="TRUE" i-minimum-length="2" i-maximum-length="36" s-validation-constraint="Not equal to" s-validation-value="NULL" --></span><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="36" SIZE="60" NAME="Name" "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:2;height:15.75pt'> <td height="46" valign=top style='padding:0in 0in 0in 0in;height:15.75pt'>&nbsp;</td> <td valign=top style='padding:0in 0in 0in 0in;height:15.75pt'>&nbsp;</td> <td valign=top style='padding:0in 0in 0in 0in;height:15.75pt'>&nbsp;</td> </tr> <tr style='mso-yfti-irow:2;height:15.75pt'> <td width="140" height="46" valign=top style='padding:0in 0in 0in 0in;height:15.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>PLEASE CONTACT ME BY:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:15.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:15.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="checkbox" CHECKED NAME="Email_Contact" VALUE="ON"><span class=text>Email <INPUT TYPE="checkbox" NAME="Phone_Contanct" VALUE="ON">Phone <INPUT TYPE="checkbox" NAME="Fax_Contact" VALUE="ON">Fax</span><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:3;height:31.5pt'> <td style='padding:0in 0in 0in 0in;height:31.5pt'>&nbsp;</td> <td style='padding:0in 0in 0in 0in;height:31.5pt'>&nbsp;</td> <td style='padding:0in 0in 0in 0in;height:31.5pt'>&nbsp;</td> </tr> <tr style='mso-yfti-irow:3;height:31.5pt'> <td width="140" style='padding:0in 0in 0in 0in;height:31.5pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>E-MAIL ADDRESS:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td style='padding:0in 0in 0in 0in;height:31.5pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" style='padding:0in 0in 0in 0in;height:31.5pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><!--webbot bot="Validation" s-validation-constraint="Greater than or equal to" s-validation-value="0" --></span><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" SIZE="60" NAME="email" "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:4;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>STREET:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="20" SIZE="60" NAME="Street" id=Street "></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:5;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>CITY:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><!--webbot bot="Validation" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="20" s-validation-constraint="Not equal to" s-validation-value="NULL" --></span><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="20" SIZE="40" NAME="City" "></span><strong><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>* </span></strong><em><b><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>STATE</span></b></em><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'> <INPUT TYPE="text" MAXLENGTH="6" SIZE="6" NAME="State" "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:6;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>ZIP:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" NAME="zip1" id=zip1></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:7;height:21.75pt'> <td width="140" style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>TELEPHONE NO.</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><!--webbot bot="Validation" s-validation-constraint="Not equal to" s-validation-value="NULL" --></span><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" SIZE="30" NAME="Phone" "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:8;height:16.5pt'> <td width="140" style='padding:0in 0in 0in 0in;height:16.5pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>FAX NO. <i>(Optional)</i> <o:p></o:p> </span></strong></p> </td> <td style='padding:0in 0in 0in 0in;height:16.5pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" style='padding:0in 0in 0in 0in;height:16.5pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" SIZE="30" NAME="Fax"></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:9;height:17.25pt'> <td valign=top style='padding:0in 0in 0in 0in;height:17.25pt'>&nbsp;</td> <td valign=top style='padding:0in 0in 0in 0in;height:17.25pt'>&nbsp;</td> <td style='padding:0in 0in 0in 0in;height:17.25pt'>&nbsp;</td> </tr> <tr style='mso-yfti-irow:9;height:17.25pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:17.25pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:17.25pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" style='padding:0in 0in 0in 0in;height:17.25pt'> <p class=MsoNormal><strong><span style='mso-fareast-font-family:"Times New Roman"'>Interested in Shipping a Gift Box:</span></strong><span style='mso-fareast-font-family: "Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:11;height:17.25pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:17.25pt'></td> <td valign=top style='padding:0in 0in 0in 0in;height:17.25pt'></td> <td width="450" style='padding:0in 0in 0in 0in;height:17.25pt'>Select Apple Variety <select name="AppleVariety" id="AppleVariety"> <option value="Golden Delicious">Golden Delicious</option> <option value="Granny Smith">Granny Smith</option> <option value="King Luscious">King Luscious</option> <option value="Late Fuji">Late Fuji</option> <option value="Mutsu">Mutsu</option> <option value="Red Delicious">Red Delicious</option> <option value="Rome Beauty ">Rome Beauty </option> <option value="Stayman">Stayman</option> <option value="Pink Lady">Pink Lady</option> </select></td> </tr> <tr style='mso-yfti-irow:12;height:15.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:15.75pt'></td> <td valign=top style='padding:0in 0in 0in 0in;height:15.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:15.75pt'> <p><INPUT TYPE="checkbox" NAME="Apples20" VALUE="ON" id=Apples20><span class=title4>20 Apple Gift Box</span> - $45, includes shipping<br> (West Coast shipments add $5)</p> </td> </tr> <tr style='mso-yfti-irow:13;height:.25in'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal><span class=text><span style='mso-fareast-font-family: "Times New Roman";border:none windowtext 1.0pt;mso-border-alt:none windowtext 0in; padding:0in'><INPUT TYPE="checkbox" NAME="Apples40" VALUE="ON" id=Apples40></span></span><span class=title4><span style='mso-fareast-font-family:"Times New Roman"; border:none windowtext 1.0pt;mso-border-alt:none windowtext 0in;padding: 0in'>40 Apple Gift Box </span></span><span class=text><span style='mso-fareast-font-family:"Times New Roman";border:none windowtext 1.0pt; mso-border-alt:none windowtext 0in;padding:0in'>- $60, includes shipping</span></span><span style='mso-fareast-font-family:"Times New Roman";border:none windowtext 1.0pt; mso-border-alt:none windowtext 0in;padding:0in'><br> <span class=text>(West Coast shipments add $5)</span></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:14;height:.25in'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal><span class=text><span style='mso-fareast-font-family: "Times New Roman";border:none windowtext 1.0pt;mso-border-alt:none windowtext 0in; padding:0in'><INPUT TYPE="checkbox" NAME="ApplesBushel" VALUE="ON" id=ApplesBushel></span></span><span class=title4><span style='mso-fareast-font-family: "Times New Roman";border:none windowtext 1.0pt;mso-border-alt:none windowtext 0in; padding:0in'>Bushel Box of Fresh Apples</span></span><span style='mso-fareast-font-family:"Times New Roman"'> - $75, includes shipping<br> (West Coast shipments add $5)<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:15;height:.25in'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:.25in'> <p class=MsoNormal><span class=text><span style='mso-fareast-font-family: "Times New Roman"'><INPUT TYPE="checkbox" NAME="Other" VALUE="ON" id=Other>Other, See My Comments Below</span></span><span style='mso-fareast-font-family: "Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:16;height:69.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:69.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'><strong>COMMENTS </strong>(OTHER) <o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:69.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:69.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><TEXTAREA ROWS="6" COLS="80" NAME="Customer_Comments"></TEXTAREA><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:17;height:21.75pt'> <td width="140" style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'><strong>SHIP TO:</strong> <o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:18;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>NAME:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="20" SIZE="60" NAME="ShipName" id=ShipName "></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:19;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>STREET:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="20" SIZE="60" NAME="ShipStreet" id=ShipStreet "></span><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:20;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>CITY:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p><span style='mso-fareast-font-family:"Times New Roman"'><!--webbot bot="Validation" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="20" s-validation-constraint="Not equal to" s-validation-value="NULL" --></span><span style='font-family:"Arial","sans-serif"'><INPUT TYPE="text" MAXLENGTH="20" SIZE="40" NAME="ShipCity" id=ShipCity "></span><strong><span style='font-size:18.0pt;font-family: "Arial","sans-serif"'>* </span></strong></p> </td> </tr> <tr style='mso-yfti-irow:21;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>STATE</span></strong><span style='mso-fareast-font-family:"Times New Roman"'>:<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="6" SIZE="10" NAME="ShipState" id=ShipState "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:22;height:21.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='font-family:"Arial","sans-serif";mso-fareast-font-family:"Times New Roman"'>ZIP:</span></strong><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:21.75pt'> <p class=MsoNormal><span style='font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'><INPUT TYPE="text" MAXLENGTH="6" SIZE="20" NAME="ShipZip" id=ShipZip "></span><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif"; mso-fareast-font-family:"Times New Roman"'>*</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:23;height:90.75pt'> <td width="140" valign=top style='padding:0in 0in 0in 0in;height:90.75pt'> <p class=MsoNormal align=right style='text-align:right'><strong><span style='mso-fareast-font-family:"Times New Roman"'>Charge Card Info</span></strong><span style='mso-fareast-font-family:"Times New Roman"'>:<o:p></o:p></span></p> </td> <td valign=top style='padding:0in 0in 0in 0in;height:90.75pt'> <p class=MsoNormal align=right style='text-align:right'><span style='mso-fareast-font-family:"Times New Roman"'>&nbsp;<o:p></o:p></span></p> </td> <td width="450" valign=top style='padding:0in 0in 0in 0in;height:90.75pt'> <p>Card Type: <SELECT NAME="select" id=select> <OPTION VALUE="MasterCard">Master Card <OPTION VALUE="VISA">Visa </SELECT></p> <p><span class=text>Account-Card No.</span> <INPUT TYPE="text" SIZE="40" NAME="CCNumber" id=CCNumber></p> <p class=text1>Exp. Date <INPUT TYPE="text" SIZE="20" NAME="ExpDate" VALUE="Mo/Year" id=ExpDate></p> </td> </tr> <tr style='mso-yfti-irow:24;mso-yfti-lastrow:yes;height:19.5pt'> <td colspan=3 style='padding:0in 0in 0in 0in;height:19.5pt'> <p align=center style='text-align:center'>Fax This Form To: (828) 685-8350 or Mail A Check With The Form <br> <br> To: Coston Farm, <strong>742 Apple Valley Road</strong>, Hendersonville NC 28792</p> </td> </tr> </table> </div> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><span style='display:none;mso-hide:all'><INPUT TYPE="hidden" NAME="hdwfail" VALUE="contact-fail.html" id=hdwfail></span><o:p></o:p></span></p> </form> </td> </tr> </table> </div> <p class=MsoNormal><span style='mso-fareast-font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> </div> </body> </html>