Print this form and fax to 1-303-277-2649 or mail to: COORS AND COMPANY BC 220 P.O. Box 4030 Golden, CO 80401-0030 Ordered By: Name    Business Name    Address  Apt/Suite    City    State    ZIP    Daytime Phone    E-mail    Date of Birth    Driver's License #    State of Driver's License    Catalog Key Code    Ship to: (No P.O. boxes please. All packages must be signed for by an adult at the time of delivery.)   Same as above address Name    Business Name    Address  Apt/Suite    City    State    ZIP    Gift Message      Item Size Item Description Quantity Price Per Item Total                                                                                     All packages are shipped UPS standard ground service unless you request Express shipping for an additional charge. Because UPS does not ship to post office boxes, be sure to indicate your street address including suite or apartment number with each order. Freight for standard USA orders (each address): Normal ground shipping in the U.S.A. is charged based on charge for order as follows: Standard Shipping Rates     • Up to $15.00, add $7.00     • $15.01 to $25.00, add $8.00     • $25.01 to $40.00, add $10.00     • $40.01 to $60.00, add $12.00     • $60.01 to $80.00, add $13.00     • $80.01 to $100.00, add $15.00     • $100.01 to $125.00, add $17.00     • $125.01 to $175.00, add $19.00     • $175.01 to $250.00, add $21.00     • $250.01 and over, add 9% of total sale Express Shipping Rates     • Express shipping for orders up to $80.00       add $11.00.     • Express shipping for orders over $80.00       add $21.00 For International orders please call us at 1-800-443-8242. Subtotal   Freight (See chart at left. Does not include the purchase of gift certificates unless ordering merchandise also.)   Express in USA (second day air) See Chart   Tax (merchandise only) See below for your rate.   Total $ If you pay by check, you must include your phone number for us to be able to process your order. AL 4%, AZ 5.6%, AR 6%, CA 7.25%, CO 2.9%, CT 6%, DC 5.75%, FL 6%, GA 4%, HI 4%, ID 6%, IL 6.25%, IN 6%, IA 5%, KS 5.3%, KY 6%, LA 4%, ME 5%, MD 6%, MA 5%, MI 6%, MN 6.5%, MS 7%, MO 4.225%, NE 5.5%, NV 6.5%, NJ 7%, NM 5%, NY 4%, NC 4.25%, ND 5%, OH 5.5%, OK 4.5%, PA 6%, RI 7%, SC 6%, SD 4%, TN 7%, TX 6.25%, UT 4.65%, VT 6%, VA 5%, WA 6.5%, WI 5%, and WY 4%. Method of Payment: Enclosed is my check/money order made payable to: COORS AND COMPANY in the amount of $___________. Gift certificate enclosed in the amount of $___________. VISA    MasterCard    Discover    American Express Account #:   Expiration date ____/____ CSV:______ Cardholder signature:___________________________________ Cardholder name:______________________________________ Have you ordered from COORS AND COMPANY before? yes no Is this a gift or for your personal use? gift personal use Would you like to be notified when the COORS AND COMPANY web site is updated? yes no Would you like to be sent our monthly e-mail newsletter? yes no Questions or comments? Send us e-mail at: coorsandco@millercoors.com Phone: 1-800-443-8242 Trademark usage by license of MillerCoors © 2008 MillerCoors, Colorado, 80401.