Free 49571.pdf - Indiana


File Size: 562.2 kB
Pages: 1
File Format: PDF
State: Indiana
Category: Government
Word Count: 174 Words, 1,067 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/49571.pdf

Download 49571.pdf ( 562.2 kB)


Preview 49571.pdf
HOOSIER HOMESTEAD SIGN ORDER
State Form 49571 (R4 /4-03) Form approved by State Board of Accounts, 2000

I would like to order the following Hoosier Homestead sign(s) from the Office of the Commissioner of Agriculture. Item Hoosier Homestead Aluminum Yard Sign @ $31.00/each (Printed on Both Sides) Postage for shipping UPS @ $10.00 (up to six signs) (If requesting more than 6 signs, call for new rate) $ $ 10.00 Amount

Total amount to remit with order form $ Name: Address: City: Telephone Number: ( ) State: Zip Code:

County that farm is located in: Date that farm was certified as a Hoosier Homestead: Award name on the original certificate: Please note that the sign(s) will be shipped by United Parcel Service (UPS) and cannot be delivered to a Post Office Box. Please make checks payable to the "State of Indiana". Return completed form and check to: Hoosier Homestead Award Program Office of the Commissioner of Agriculture ISTA Center - Suite 416 150 West Market Street Indianapolis, Indiana 46204-2810 OFFICE USE ONLY
Transaction # Check # Initials ID #