Licklog Farms Mail Order Form 

                          Name: 

      Mailing Address:

   Shipping Address:      2  Shipping Address :             3 Shipping Address:           

                              City:                                       City:                                           City: 

                                 St:                                                                St:                                                                   St:   

                                Zip:                                                  Zip:                                                       Zip: 

          Email Address:    Phone:    Cell Phone:

           Delivery Date:              22 inch decorated Wreaths:     Quantity    Each Wreath is $30.00 plus shipping and  handling. 

                                                                                                                                                                                         Shipping and handling will be an additional $15.00  

     Payment Method:                       Visa             MasterCard         Check 

      If you are using a credit card, we will contact you upon receiving this form to finalize payment. 

      All payments are due upon order placement.  Visa, MasterCard, Certified Cashiers Check, personal check, or Money orders accepted. 

      Is the wreath a gift?     Yes     No    Message to put on Gift Card: 

    Orders will be shipped to you  on date specified Please remit to:

                                                                                                     Licklog Farms

                                                                                                     897 Licklog Rd

                                                                                                    Newland NC 28657

Please submit this  form or print off  this order form and  mail to address listed above.