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Name:
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Email Address:
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Address 1:
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Address 2:
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City:
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State or Province:
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Zip/Postal Code:
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Country:
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Daytime Phone:
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How did you hear about us?:
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Name of the person the tree is dedicated to?:
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How would you like your dedication worded?:
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Who do you wish to be listed as the purchaser?:
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| Is this tree dedication for a:
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_________gift (happy occasion),
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_________grief (in memory)
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Recipient’s Name:
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Recipient’s Mailing Address:
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Recipient’s City:
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Recipient’s State or Province:
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Recipient's Postal Code:
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Recipient's Country:
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Recipient’s Phone Number:
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Do you want us to mail the
dedication package to:
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____Your Address to Give to Recipient,
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____Recipient’s Address
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| Tree Species:
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___Oak $199.00,
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___Maple $179.00,
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___Pine $149.00,
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___Spruce $129.00
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| Gift Packages: See Below
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| ___Deluxe $49.00
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___Standard FREE
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___Forest Update $49.00
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| ___Newsletter $19.00
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___Natural Granite Bench $599.00
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___Natural Granite Stone $499.00
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| ___Forest KeepStone $99.00
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| Order Processing Options:
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____Next Day Processing $9.00,
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____Regular 2-5 days Free
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| Mailing Options for Certificate:
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___Priority $10.00,
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___First Class USPS Free
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| Would you like your dedication listed on our Memory Lane page on the website? (Free Service)
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___Yes
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___No
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| Payment Method:
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___Mastercard
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___Visa
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___American Express
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___Discover
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___Check
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___Money Order
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Credit Card or Check Number:
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Expiration Date:
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Name on Credit Card:
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Referring Company:
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