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

CONNOISSEUR MEMBERSHIP OPTION:
  Triple Salsa Tribute ($27.99 x 3).........................................$ 83.97

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.)

  I verify that the shipping information I have provided is correct and complete 
to ensure proper delivery of this package. I understand that if UPS is required to make a change or correction to 
the shipping information I have supplied, I will be charged the $10.00 address correction fee that UPS has charged.