Home Health and Hospice Care “Completing the Circle of Care” 2402 Wayne Memorial Drive Goldsboro, NC 27534 Phone 919-735-1387 Fax 919-735-8460

"Cooking with Care" Order Form

Your Home Address: Name: _________________________________________ Company Name:__________________________________ Address: _______________________________________ City, St, Zip: ___________________________________ Phone: _________________________________________

Ship To (if different from your home address): Name: _________________________________________ Company Name:__________________________________ Address: _______________________________________ City, St, Zip: ___________________________________ Phone: _________________________________________

QTY	DESCRIPTION		UNIT PRICE	TOTAL
	Cooking with Care. . .a taste of 3HC		Each at $15.00
		SUBTOTAL
		SHIPPING & HANDLING		$2.00
		TOTAL

1. Please remember to enclose your payment with your order. 2. Please allow two to three weeks for delivery. 3. Send all correspondence to: Ms. Lee Gray c/o 3HC-Cooking with Care 2402 Wayne Memorial Drive Goldsboro, NC 27534 Phone: 919-735-1387	Payment Method: ___ I am enclosing a check or money order with my order. ___ Please charge to my (circle one) Visa, MasterCard,       American Express: Account Number: _________________________________ Expiration Date: __________________________________
	Signature Date

Thank you for your support of 3HC's Indigent Care Fund.

3HC is a 501(c)(3) agency and all donations are

tax deductible as allowed by IRS regulations.