The Hosta Farm
3501 Louisa Road Coeburn VA 24230 
Print this form and use it for reference when placing your order by mail
We accept checks, money orders, Visa and Mastercard

(A) Ship To: (name and address)
We ship via UPS Ground - we will email tracking #
(B) Bill To: (please fill in bill to information if
this differs from your shipping address)
Name: _____________________________ Name: _________________________
Address: ___________________________ E-mail: _________________________
Address:____________________________ Address: ________________________
City:________________________ State:___ 
Province:______ Zip:______ Country:_______
Address: ________________________
Telephone:__________________________ City:_____________________ State:___ 
County:________ Zip:____ Country:_______
E-mail: _____________________________ Daytime Telephone:________________
Above information must match your issuing banks records

(C) List of Items: 

Item #: Item Name: Qty: Price each Total:

Continue to next page to provide us with your shipping and billing details



(D) Totals & Shipping:  

Shipping is one flat rate for all orders.

Please add $11.95 for shipping on all orders.

Shipping Season begins week of 3/25  and continues through the last week of June

Please give us your desired shipping date _______________________________

Merchandise Total:_______________
Shipping  $11.95
ONLY add 4.5% sales tax if you are a resident of Virginia:_______

(E) Method of Payment:
___ Check or money order (payable to "Gorge Top Gardens")
___ Mastercard  ___ Visa 

Credit card #____________________________ & exp. date:____________
800 # on back of credit card__________________________

I agree to pay the above total amount according to card issuer agreement   X_________________________Date_______

Thank You