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Box Scheme Order Form

First Name:
Last Name:
Phone:
Alternative Phone:
Email:
Home Address including postcode :
Delivery Address: (if Different from above)
Order for (please tick)	Large box (£13.45) Medium box (£10.75) Small box (£8.25) Potato and Onion Free box (£10.35) Mini box (£6.50) Extra bag of potatoes (£1.80)
Please deliver	Weekly Fortnightly Other (please state below)
How / where did you find out about our box scheme?
Preferred payment method	Standing Order: Our bank details are: Account no: 70846553 Sort code: 089250 Address: The Co-operative Bank, PO Box 250, Delf House, Skelmersdale, WN8 6WT. Please ask your bank to use your name as the reference. Cheque: Please make cheques payable to Vallis Veg Boxes. Please Write your name and address on the back of cheques
Boxes will be left outside your front door. If you require them to be left elsewhere, please state below
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