Print This Form and Mail Check or Money Order To:

Juniata Stinking Rose
719 Washington Ave.
Mifflintown, PA 17059

SCAPES ORDER FORM

Name:___________________________________________

Address:_________________________________________

City/State/Zip:___________________________________

Phone:___________________________________________

SCAPES

TOTAL(lbs):_______________________________________

cost per pound ($5.00 before June 1, 2003)

Shipping and handling $3.50 1st pound

$1.50 each additional pound

Enter Total Pounds________________________________

Amount Enclosed__$_______________________________