Bench Order Form

You can call in an order, or fax or mail this form to place an order. If you have any question

or need help filling out the form, please call. 1-866-665-2621.

Phone: 1-866-665-2621 or 605-665-2621

FAX: 1-605-665-2621

Address: Countryside Mfg. Inc.

30793 435th Ave.

Yankton, SD 57078

Name:_______________________________________________________________

Shipping Address:______________________________________________________

______________________________________________________

E-mail: ______________________________________________________________

Daytime Phone: _______________________________

Payment Method:

Check_______ Money Order or Certified Check________ Credit Card________ PayPal_________

Credit Card Type: (Circle One) VISA MASTERCARD DISCOVER

Number:___________________________________ Exp. Date______________

Security Code - The last 3 digits in or close to the signature strip on back of card ___________

Name on card:______________________________________

Billing address of credit card if different from above:_________________________________________________

__________________________________________________

*All information will remain confidential and will not be given or sold to any other companies.

Type of Bench: Deacon's Bench _______ Open ________

Custom Size: _______________________ Please Call for Prices on Custom Sizes

Wood Balls: Yes_______ No ________

Choose Type of Wood:

Oak____________ Cherry_____________

Walnut__________ Other:_____________

Oak/Walnut Combination_____________

Cedar Lining: Yes________ No________

The back of the storage area on the Deacon's Bench is flat. It can be ordered with Raised Panels and Trim Like the Front for additional cost.

Yes________

No ________

Choose Stain: (Circle One)
Oak:	Walnut or Cherry:
Early American: Medium golden stain	Natural Walnut - may have light streaks
Provincial: Medium slightly reddish stain	Walnut
Fruitwood: Light	Cherry Stain on Walnut
Natural Oak - very light	Natural Cherry
	Dark Cherry
Other:__________________

Etching Design: Please write in etching design number -

Write in none if you don't want an etching

Design:__________________ Custom:__________________________

For custom designs, please include any special instructions below.

Do not fax designs, or images. Please scan these at 300-600 dpi and e-mail them or mail in the original.

Originals will be returned with the order. See the Photo Information page for more directions.

Special Instructions:

____________________________________________________________________________________

Please fill in Item #, Description, & Quantity. Leave the Price blank if you want us to figure the cost.

Item #	Description	Quantity	Price



Ground Shipping Charges will be added based on weight & distance. If you want a shipping price, please call or email us for a quote.
Please call for pricing on other types of wood or custom sizes

Credit card will not be charged until the bench ships.