Kombucha Products Order Form


Please print page, fill in form, and mail with check or money order
(payable to H.D. Brown) to:

H.D. Brown/Kombucha
203 George St.
North Syracuse, New York 13212-1311


Name: ______________________________________________

Address:____________________________________________

City:_________________________ State:___________

Zip code:__________

Quantity: -------------------- Item: -------------------------- price ------------- Total(s)

______ 2 Kombucha Cultures & Instructions ------- $20.00 ---------- ________

Above price includes shipping and handling within U.S. via
U.S. Postal Priority Mail.


----------------------------------------------------------------------------Total _________

optional;

E-mail: ________________

Phone #: _______________

Additional instructions/comments: