Dainichi Koi Food Order Form

KOI FOOD ORDER FORM

Fill Out Order Form and SUBMIT by E-mail

or Select PRINT on your Web Browser and FAX or MAIL to:

580 N Berry Street
Brea, CA 92821 USA
Tel 714.672.0855 • Fax 714.672.0852

For information or comments please contact us: Email info@dainichi.com or Toll Free 877.366.3434 (FOOD-4-FISH)

Customer Information
First Name*
Last Name*
	Existing Customer (Input Changes Only)
	Note: E-mailed Final Invoice also serves as your Order Confirmation.
E-mail*	Required
Phone	Alt Phone Include Area Code
Bill To Street Address*
Bill To City / State / Zip*	City State Zip
Bill To Foreign State / Country*	Foreign State Country

Ship To Customer Information*	Same as "Bill To" Information (Skip "Ship To")
Ship To Street Address
Ship To City / State / Zip	City State Zip
Ship To Foreign State / Country	Foreign State Country

Notify you of specials or new products?
How did you hear about us?

Select Payment Method*
Credit Card Number	Exp Date Month Year
Credit Card Security Code	CVC Code 3 Digit Number on Signature Panel

•

KOI FOOD
QTY	FORMULA	PELLET	BAG SIZE	BAG PRICE	TOTAL
NEW! Toyoma Koi - Breeder Formulas
	ALL-SEASON PRO
	ALL-SEASON PRO
	PREMIUM PRO
	PREMIUM PRO
Dainichi Koi Formulas
	ALL-SEASON
	ALL-SEASON
	GROWTH PLUS
	GROWTH PLUS
	PREMIUM
	PREMIUM
	COLOR INTENSIFIER
	COLOR INTENSIFIER
ORDER NOTES: • All Pellets are FLOATING. • SINKING Pellets are sometimes available upon request. • Small / Medium Mix Pellet is available in 5.5 lb only.			SUB-TOTAL (EXCLUDES Shipping & Tax)*

*7.75% Sales Tax: California Residents Only.

Shipping & Handling

Shipping by UPS Ground Unless Specified Otherwise.

Up to 1.5 lbs (and all shipments to PR, AK and HI)	Priority Mail	$6.00
1.5 lbs and up	UPS	Weight Dependent

Questions, Comments or Special Requests