Order Form

Mailing Address:
City: State:Zip:
Phone:       Email:

Captain Mike's  Original
Quantity:   1-Pack Crate     Price:   $      9.95
Quantity:   2-Pack Crate     Price:   $    19.95
Quantity:   4-Pack Crate     Price:   $    39.95
Quantity:   6-Pack Crate     Price:   $    59.95
Quantity:  12-Pack Case     Price:   $  119.95

Captain Mike's Sodium Free
Quantity:   1-Pack Crate    Price:   $      9.95
Quantity:   2-Pack Crate    Price:   $    19.95
Quantity:   4-Pack Crate    Price:   $    39.95
Quantity:   6-Pack Crate    Price:   $    59.95
Quantity:  12-Pack Case    Price:   $  119.95

E-mail name to put on box or call toll-free 1-888-xxx-xxxx
Custom gift boxes available for $50 and up.
Create an extra special gift someone will remember.
Call 1-888-xxx-xxxx for details.

Shipping Instructions

Shipping Address One:

Name:              Phone:
Shipping Address:
City:    State:    Zip:
Item numbers: Quantities:

Shipping Address Two:

Name:                Phone:
Shipping Address:
City:     State:       Zip:
Item numbers: Quantities:

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For credit card orders please call us toll free at 1-888-xxx-xxxx
or E-mail us your phone number and a convenient time to for us to call you.