Print this form and fax to 1-303-277-2649 or mail to:

P.O. Box 4030
Golden, CO 80401-0030

Ordered By:
Business Name   

State    ZIP   
Daytime Phone   
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
Business Name   

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.

(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 7.5%, CO 2.9%, CT 6.35%, DC 6%, FL 6%, GA 4%, HI 4%, ID 6%, IL 6.25%, IN 7%, IA 6%, KS 6.3%, KY 6%, LA 4%, MA 6.25%, MD 6%, ME 5.5%, MI 6%, MN 6.875%, MS 7%, MO 4.225%, NE 7%, ND 5%, NJ 7%, NM 5.125%, NV 6.85%, NC 4.75%, NY 4%,OH 5.5%, OK 4.5%, PA 6%, RI 7%, SC 6%, SD 4%, TN 9.25%, TX 6.25%, UT 4.7%, VT 6%, VA 5.3%, WA 6.5%, WI 5%, WY 4%,and WV 6%.

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:

Phone: 1-800-443-8242

Trademark usage by license of MillerCoors
2012 MillerCoors, Colorado, 80401.