Atiu Coffee - Organic Gourmet Coffee Mail Order Form

We have prepared this order form for you to fill in and send to us. We regret that we cannot except orders for less than NZ$ 50.00. Your shipment must be insured, insurance costs NZ$ 1.50 + NZ$1.00 per each NZ$ 100.00 of insured value and has to be added to the total amount resulting from your order.

For customers in the U.S.A., a surcharge of US$ 19.95 applies for prior registration with US FDA, US Customs and US Border Protection Service.

Atiu Coffee	Bag size	Price	Please send	Bag Size	Price	Please send
Dark Roast (ground)	250 gr	$ 9.50	bags	850 gr	$ 23.40	bags
Dark Roast (whole beans)	250 gr	$ 9.50	bags	750 gr	$ 20.60	bags
Medium Roast (ground)	250 gr	$ 9.50	bags	1 kg	$ 25.70	bags
Medium Roast (whole beans)	250 gr	$ 9.50	bags	1 kg	$ 25.70	bags

Please fill in your details
Surname, Name
Postal Address
City
State / Region
Zip / Postal Code
Country
Phone
Fax
Email
Shipping	Only air mail available, please see price table below.
(for Fax)* please cross out what is not applicable	Your signature and date :

If you don't want to use the Internet facilities we offer you, you can also send us a copy of this completed form by

• Fax: (+682) 33032
• Air mail: to our postal address:
  Atiu Coffee Factory Ltd.
  P.O. Box 13 - Atiu
  Atiu, Cook Islands (South Pacific)

Postage	Australia/New Zealand/ Oceania	America/ Canada	Europe
Air Mail up to 1 kg	$ 26.70	$ 31.10	$ 53.50
each additional 500 gr	$ 4.90	$ 12.10	$ 19.50

For secure payment with your credit card, please click here.

© Atiu Coffee 2010