Hearthstone Log and Timber Frame Homes Fax Back Order Form

	Fax-Back Order Form Please fill out and fax to (937) 374-1596 Payment Options: (a) fax back with your credit card information or (b) print out and mail with your check to: R.P. Zimpfer Construction Company 2230 Stewart Road, Xenia, OH 45385
*Name____________________________________________**
*Address__________________________________________**
*Address__________________________________________**
*City__________________________________ State____________*
*Zip Code_______________________**
*Home Phone _____________________ Work Phone______________________*
Building Site Location ________________________(County) ________________(State)
When do you plan to begin building?_________________(Mo.) _______________(Yr.)
Check Method Of Payment: ____MasterCard ____Visa ____AMEX
____Check (Make checks payable to Hearthstone, Inc.)
Card No.:_______________________________________ Exp. Date:___________________
Name as it appears on card:____________________________________________