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Golden Plains Ag. T ech
Box 307
Colby Kansas 67701
Fax Order Form
(785)-462-3411
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Product Code Quantity Product Description............ Price each Total.............
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Shipping and handling is $5.00 for the First item, and then $2.00 for each additifnal item.

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Card No. ____________________________ Exp Date ___/____/____

Your Signature ______________________________

Note: Print this form and Fax to us. We will ship immediately via UPS. Expect delivery in 7 to 10 days.

Your Name _____________________________

Address Street_____________________________________

City_________________________State _______Zip______

Phone No. _____________________________________