Pierogi Palace
- Order Form -

Please Print out this Form.   Then fax or mail it back to us or call us with the information.
Date  
Your Name  
Your Address  
 
Your Telephone No.    (               ) 
Your e-mail address  
Shipping Address
(if different from yours)		  
 

***** All prices are subject to change. *****

T-shirt Design Style & Saying #:
Price + Shipping

  Size  

Quantity
      Total       

 

$15.00 + $4.50 S/H
     

Rum Cake

Price + Shipping

# of Cakes

      Total     
Babciu's Rum Cake

$25.00 + S/H
    

Rice Cake

Price + Shipping

# of Cakes

      Total     
Grandma's Rice Cake

$25.00 + S/H
    

 Variety #

Pierogi Filling
Pierogi with "meat" or "crabmeat" available only on site.

No. of Packs

Price / Pack

Totals
         
         
         
         
         
         

 Pierogi Total Price:

  

 Pierogi Shipping Cost (Click Here):

  

 Grand Total Amount Due (Pierogi + Any other Specialty Items) :

  

Method of Payment
Please Check One
Cash or Money Order  
Personal Check  
Credit Card
  
   >> Credit Card information    >>
Credit Card information
 Type of Credit Card  
 Name on the Card  
 Card Number  
 Expiration Date  
 Signature  X

Please Fax or Mail this order form to:
Pierogi Palace
17 Spring Street, Oil City, PA 16301

Toll Free: (877) 727-8359    Phone: (814) 677-4090    FAX: (814) 678-2221

pierogi@usachoice.net      www.pierogipalace.com

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