If you wish to fax your coffee order to us please print this form, fill it out and fax it to:   1-808-331-1474
Name: _______________________________________________________
Phone #: _______________________________________________________
Address: _______________________________________________________
City: _______________________________________________________
State: _______________________________________________________
Zip Code: _______________________________________________________
Country: _______________________________________________________
Order Info:
Kona Cafe Coffee - 1 Pound Size Quantity: _______ Roast
(Check One):
Full City: ___
Viennese: ___
French: ___
Kona Cafe Coffee - 3 Pound Size Quantity: _______ Roast
(Check One):
Full City: ___
Viennese: ___
French: ___
Kona Cafe Coffee - 5 Pound Size Quantity: _______ Roast
(Check One):
Full City: ___
Viennese: ___
French: ___
Kona Cafe Coffee Club 1 Pound sent monthly for a year Quantity: _______ Roast
(Check One):
Full City: ___
Viennese: ___
French: ___
Kona Cafe Coffee Club 2 Pounds sent every second month for a year Quantity: _______ Roast
(Check One):
Full City: ___
Viennese: ___
French: ___
Payment Info:
Credit Card: Visa
Master Card
American Express
Discover Card
Card Number: _____________________________________________
Name as it appears on card: _____________________________________________
Card expiry date: _____________________________________________
Thank You!