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Please note: If this is a gift purchase, the GIFT RECIPIENT'S E-MAIL ADDRESS IS NOT REQUIRED. All other information is required.

PURCHASER INFORMATION:                       GIFT RECIPIENT INFORMATION:
                                             (Please complete one form for each gift.)

Name: _________________________________      Name: _________________________________

Address: ______________________________      Address: ______________________________ (We cannot ship to PO Boxes)

City: _________________________________      City: _________________________________

State/Zip: ____________________________      State/Zip: ____________________________

Home Phone: ___________________________      Home Phone: ___________________________ (Required)

Fax: __________________________________      Fax: __________________________________

Email: ________________________________      Email: ________________________________

Gift Occasion: _____________________________________________________________________

Gift Card Message (15 Words Max): __________________________________________________

____________________________________________________________________________________

Is this a RENEWAL? (Yes/No) ________________________________________________________

How Did You Hear About Us? _________________________________________________________


WHICH MEMBERSHIP WOULD YOU LIKE TO ORDER:

STANDARD MEMBERSHIP OPTION:
  Salsa Summit ($19.99 x 12)................................................$239.88

  Six Salsa Salute ($20.99 x 6).............................................$125.94

  Triple Salsa Tribute ($20.99 x 3).........................................$ 62.97

  Personalize:    # of Months (3 mo. minimum) __________ x $20.99 = _________ Total


CONNOISSEUR MEMBERSHIP OPTION:
  Salsa Summit ($26.99 x 12)................................................$323.88

  Six Salsa Salute ($27.99 x 6).............................................$167.94

  Triple Salsa Tribute ($27.99 x 3).........................................$ 83.97

  Personalize:    # of Months (3 mo. minimum) __________ x $27.99 = _________ Total


 CONNOISSEUR (No Chips) OR  GOURMET COMBO MEMBERSHIP OPTIONS:
  Salsa Summit ($23.99 x 12)................................................$287.88

  Six Salsa Salute ($24.99 x 6).............................................$149.94

  Triple Salsa Tribute ($24.99 x 3).........................................$ 74.97

  Personalize:    # of Months (3 mo. minimum) __________ x $27.99 = _________ Total


ORDER DETAILS:

  • Start Month: (Enter Month) _______________________

  • Heat Preference (Select One):     ____Medium  ____Medium to Hot  ____Hot

  • Special Instructions:  ___________________________________________________________
  (Write any Promotional Code above)
  
Please add an ADDITIONAL $5.00 per month for shipments to Alaska, Hawaii, or an APO/FPO address.

PAYMENT METHOD:

  Credit Card (Select One):   ____MC  ____Visa  ____Amex  ____Disc

  • Billing Address (if different):  _________________________________________________

    Name On Credit Card: _________________________     _____________________________
                         Print Name                       Signature

    Card Number: _____________________________________  Expiration: ________________

  Money Order Enclosed (Sorry- We can not accept personal checks.)
    • Fax to: 925-685-6141 or     Send to: Salsa2U, P.O. Box 5696, Concord, CA 94524

    Back to Salsa2U.