Cortez Cash Order Form
Use this form to order Cortez Cash for yourself or for a Gift Recipient. Please indicate if this is a gift by checking the appropriate box.
Bill To (Name):
Address:
City:
State:
Zip/Postal Code:
Daytime Phone:
Purchaser's Contact Email:
Is this order a Gift?
Yes
No
Send this order to the Billing Address above?
Yes
No
Please complete Shipping Information below (if different than Billing Information):
Ship To (Name):
Shipping Address:
City:
State:
Zip/Postal Code:
Daytime Phone:
Recipient's Contact Email:
Indicate the amount of each Cortez Cash denomination ($1, $5, $10, $20) you are ordering. Your Total Order will be calculated in the box below:
ONES:
1
2
3
4
5
10
15
20
25
50
75
100
FIVES:
1
2
3
4
5
10
15
20
25
50
75
100
TENS:
1
2
3
4
5
10
15
20
25
50
75
100
TWENTIES:
1
2
3
4
5
10
15
20
25
50
75
100
Total Order:
(Remove checks to modify total)
Please select your payment method:
Personal Check
Money Order
Cashier's Check
Check# enclosed:
Please
PRINT THIS COMPLETED ORDER FORM
and enclose payment with your order.
Make checks payable to:
CORTEZ RETAIL ENHANCEMENT ASSOCIATION
PO Box 1715, CORTEZ, COLORADO 81321
Allow 3 weeks for postal mail delivery of all orders.