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.
Phone: 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. |
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Please call for pricing on other types of wood or custom sizes |
Credit card will not be charged until the bench ships.