Hosta Hideaway
511 East Salem
Indianola, IA 50125
(515) 961-8213
dkripp@mchsi.com
Shipping Information / Contact Information
Full Name: ____________________ Date ____/____/______
Address 1: ____________________ E-mail ________________
Address 2: ____________________ Phone Number (____)-____-______
City ____________________ Work Phone: (____)-____-______
State _____    
Postal Code ________-_____    

Please fill in and print out this form and send it with payment to the address above.
Thanks

Product Name Price Quantity Total
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________
____________________ $________ ____ $________