Shape Community Center

FRUIT & VEGETABLE CO-OP ORDER FORM

Please Complete/Print This Form If You Would Like To Order A Co-Op(s) And Mail To the Address Below
(please mail one (1) week in advance to asure receipt of payment)

Name

Birthdate

Address City State Zip

Phone Home Cell Work Fax

TDL / ID State Exp Date

E-mail New Member Yes No Date

FV $35.00 = $ FO $30.00 = $

Total Amt Enclosed $ CK or MO # Co-Op Date

Credit Card : Visa MC AX Discover #

Signature Date

	Make Personal / Cashier's Check or Money Orders Payable To: S.H.A.P.E. Community Center P.O. Box 8428 • Houston, TX • 77288-8428
	ALL RETURNED CHECK’S WILL BE ASSESSED A $25.00 FEE

Administrative Office 3903 Almeda Rd. • Houston, TX 77004   713-521-0629 Office •  713-521-1185 Fax
Family Center 3815 Live Oak •  Houston, TX 77004 • 713-521-0641 Office •  713-526-5164 Fax
Web: www.shape.org   E-mail: shape@shape.org