Please print out this form, fill it in, then fax or mail it back to us. You can also call us with the information.

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

Your Information
Date
Your Name
Your Address
Your Telephone No.
Your e-mail address
Shipping Address (if different from yours)

Specialty Items
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

Homemade Pierogi
Variety #	Pierogi Filling Pierogi with "meat"available only on site.	No. of Packs	Price / Pack	Totals
Pierogi Total Price:
Pierogi Shipping Cost (Click Here):
Specialty Item Total Price:
Grand Total Amount Due:

Method of Payment: Please Check One
Cash or Money Order
Personal Check
Credit Card (Visa or Mastercard accepted)

Credit Card information
Type of Credit Card
Name on the Card
Card Number
Expiration Date
Signature

Please Fax or Mail this order form to:

Pierogi Palace

17 Spring Street
Oil City, PA 16301
Toll Free: 877-727-8359
Tel: 814-677-4090
Fax: 814-678-2221