PRINT FORM AND SEND VIA MAIL OR FAX TO:

Rio Syrup Company, Inc.
2311 Chestnut Street, Saint Louis, Missouri 63103-2298 USA
(phone) 1-800-325-7666 (fax) 314-436-7707

CONTACT INFORMATION:
	Date: Name: Phone: Fax: Address: City, State, Zip:

ORDER INFORMATION (Consult "RIO Home Kits and Packs" in the Home Users Section and use the Flavor Finder to select the flavors you would like to order):
	Product Code Size Product Name (Flavor, Syrup/Conc/Slush)

PAYMENT INFORMATION:
	MC VISA DIS ____ AX SIGNATURE: CARD#: EXP. DATE:

TO ORDER BY CHECK OR MONEY ORDER PLEASE MAKE CHECK PAYABLE TO: RIO SYRUP COMPANY