Order Form Jefferson County Effective March 2017 Please complete all info on reverse (print clearly).

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1 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY TAXABLE ITEMS Diet Coke 20 oz. Plastic Bottle $1.85 / EA 2285 DRINKS Faygo Grape Soda 20 oz. Plastic Bottle $1.85 / EA 6502 Coffee Keefe 4 oz. Instant Coffee K H $7.99 / EA 21 Sprite 20 oz. Plastic Bottle $1.85 / EA 3118 Nescafe 1.5 grams Taster s Choice Stick K G $0.50 / EA 4478 FOOD & SNACKS Cereal Bars Hot Cocoa Golden Valley 1.3 oz. Strawberry Cereal Bar K $0.70 / EA 6045 Keefe.8 oz. Single Serve Hot Cocoa G $0.75 / EA 114 Quaker.84 oz. Chewy Chocolate Chip Granola Bar K $0.70 / EA 9366 Sugar & Sweetener Sugar Packet (1 Pk.) K $0.08 / EA 136 Pastries & Snack Cakes Cloverhill 4.25 oz. Cherry Cheese Danish K $1.45 / EA 4647 Sweetmate Saccharin Sweetener (1 Pk.) K $0.08 / EA 9719 Kellogg s 1.3 oz. Original Rice Krispies Treats $1.25 / EA 2381 Creamer Cafe Valet Non-Dairy Creamer (1 Pk.) K H $0.15 / EA 237 Market Square Bakery 12 oz. Blueberry ZuZus (6 Pk. Donuts) K $5.00 / EA 6048 Drink Mixes Market Square Bakery 4.75 oz. Mega Buneez K $1.40 / EA 6044 Gatorade 7.5 oz. Fruit Punch Drink Mix H R $3.75 / EA 7979 Market Square Bakery 4 oz. Choc. Creme-Filled Cupcakes (2 Pk.) K C $1.60 / EA 6060 Hawaiian Punch Singles To Go.092 oz. SF Fruit Juicy Red Drink Mix $0.90 / EA 6470 Market Square Bakery 4 oz. Iced Swirl Cinnamon Roll K C $1.50 / EA 6057 Sweet Fusions.5 oz. Orange Breakfast Drink Mix (1 Pk.) $0.35 / EA Market Square Bakery 4 oz. Strawberry ZuZus (2 Pk. Donuts) K $1.25 / EA 6046 Wyler s Light.10 oz. SF Singles To Go Strawberry Lemonade Drink Mix (1 Pk.) K Wyler s Light.13 oz. Singles To Go Lemonade SF Drink Mix (1 Pk.) K Wyler s Light.1 oz. Singles to Go Iced Tea w/lemon Drink Mix (1 Pk.) K $0.90 / EA $0.90 / EA $0.90 / EA Market Square Bakery 6 oz. Monster Iced Honey Bun K C $1.40 / EA 6043 Moon Pie 2.75 oz. Double Decker - Banana Flavor C $0.85 / EA 542 Moon Pie 2.75 oz. Double Decker - Chocolate Flavor $0.85 / EA 540 Moon Pie 2.75 oz. Double Decker - Strawberry Flavor C $0.85 / EA 562 Soda & Water Bottled Water 16.9 oz. Clear Plastic $1.25 / EA Coke 20 oz. Plastic Bottle $1.85 / EA 2284 Otis Spunkmeyer 3.5 oz. Marble Loaf Cake K $1.75 / EA Otis Spunkmeyer 4 oz. Cinnamon Crumb Loaf Cake K $1.75 / EA Otis Spunkmeyer 4 oz. Lemon Loaf Cake with Lemon Icing K $1.75 / EA

2 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY Moon Lodge 1.75 oz. Hot, Hot, Hot! Peanuts K C G $0.70 / EA 7551 Chips & Snacks Andy Capp s.85 oz. Hot Fries $1.02 / EA 6743 Moon Lodge 1.75 oz. Salted Peanuts K C G $0.70 / EA 7550 Cactus Annie s 1.5 oz. Habanero Tortilla Chips K H C G $1.02 / EA 7666 Crackers Austin 1.45 oz. Peanut Butter & Jelly Crackers $0.75 / EA Cactus Annie s 1.5 oz. Hot & Spicy Corn Chips K H $1.02 / EA 7999 Cheez-It 1.5 oz. Cheddar Crackers K $0.95 / EA 9590 Cactus Annie s 1.5 oz. Nacho Cheese Tortilla Chips K H G $1.00 / EA 920 Golden Valley 4.2 oz. Saltine Crackers (One Sleeve) K $1.55 / EA 7914 Cactus Annie s 2 oz. Hot & Spicy Pork Rinds C G S $1.49 / EA 1266 Keebler 5.25 oz. Club Crackers K $2.35 / EA Cheetos 2 oz. Cheese Crunchy C G $1.05 / EA 7689 Cookies Doritos 1.75 oz. Cool Ranch Chips $1.05 / EA Market Square Bakery 2.75 oz. Soft Baked Oatmeal Raisin Cookies (2 Pk.) K $0.90 / EA 7648 Doritos 1.75 oz. Nacho Cheese Chips $1.05 / EA Fritos 2 oz. Chili Cheese Corn Chips $1.05 / EA Moon Lodge 1.5 oz. BBQ Potato Chips K H $1.02 / EA 6023 Moon Lodge 1.5 oz. Buffalo Wing Blue Cheese Potato Chips K $1.00 / EA Moon Lodge 1.5 oz. Regular Potato Chips K H $1.00 / EA 6022 Moon Lodge 1.5 oz. Sour Cream and Onion Potato Chips K H $1.02 / EA 6024 Snyder s 2.25 oz. Jalapeno Pretzel Pieces K $1.50 / EA 2299 The Whole Shabang 1.5 oz. Potato Chips K H $1.05 / EA 6025 Market Square Bakery 6 oz. Chocolate Chip Cookies K H $1.80 / EA 6072 Market Square Bakery 6 oz. Duplex Creme Cookies K H $1.80 / EA Market Square Bakery 6 oz. Iced Oatmeal Cookies K H $1.80 / EA 6071 Market Square Bakery 6 oz. Vanilla Creme Cookies K H $1.80 / EA Oreo 2.4 oz. Cookies $0.85 / EA Vanilla Wafers 1.75 oz. Sugar Free $1.80 / EA 3020 Candy 3 Musketeers 1.92 oz. Bar K $1.35 / EA Popcorn Moon Lodge 3.53 oz. Caramel Popcorn K H G $1.50 / EA 7758 Moon Lodge 5 oz. Jalapeno Cheddar Popcorn $2.50 / EA Moon Lodge 5 oz. White Cheddar Popcorn K H G $2.65 / EA 5133 Nuts Kings Nut 3.5 oz. Spicy Cajun Mix $2.20 / EA Baby Ruth 2.1 oz. Bar K G $1.35 / EA 844 E.Z. Digby s 2.75 oz. Tootsie Rolls C $1.40 / EA E.Z. Digby s 3 oz. Atomic Fire Balls C $1.50 / EA E.Z. Digby s 4.25 oz. Rootbeer Barrels C $1.35 / EA E.Z. Digby s Assorted 3.25 oz. Now & Later C $1.85 / EA 40637

3 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY Hershey s 1.45 oz. Milk Chocolate Bar w/almonds K $1.35 / EA 1779 Spices & Seasonings Jolly Rancher 3.7 oz. Assorted Flavors C $2.25 / EA Iodized Salt Packet $0.06 / EA 520 Kit Kat 1.5 oz. Bar K $1.35 / EA 5409 Pepper Packet $0.06 / EA 519 M&M s 1.69 oz. Plain Candy K $1.35 / EA Spreads Squeez-Ums 1.12 oz. Peanut Butter (1 each) K H G $0.70 / EA 3786 M&M s 1.74 oz. Peanut Candy K G $1.35 / EA 955 Squeez-Ums 1 oz. Grape Jelly H G $0.50 / EA 4787 Milky Way 1.84 oz. Bar K $1.35 / EA Condiments Nestle 1.9 oz. Butterfinger Bar K G $1.35 / EA Squeez-Ums.15 oz. Mustard (12 Pk.) K H G $1.20 / STR 6513 Pay Day 1.85 oz. Candy Bar K $1.35 / EA 985 Squeez-Ums.24 oz. Hot Sauce (12 Pk.) K H G $1.79 / STR 6517 Reese s 1.5 oz. Peanut Butter Cups K G $1.35 / EA 1949 Squeez-Ums.31 oz. Ketchup (12 Pk.) K H G $1.20 / STR 6514 Sathers 1.75 oz. Sugar Free Wild Fruit C $1.10 / EA Squeez-Ums.31 oz. Mayo Single Packet K H G $0.20 / EA 6510 Sathers 3.75 oz. All Stars Assorted Candies C $1.35 / EA Titos.7 oz. Pickled Jalapeno Pepper Slices C G S $0.95 / EA 1590 Sathers 3.75 oz. Starlite Mints C $1.35 / EA Sauces Sathers 4.25 oz. Butterscotch Discs C $1.55 / EA Cactus Annie s 15.5 oz. Squeeze Salsa (Medium) C R G $4.40 / EA 179 Sathers 4.25 oz. Lemon Drops C $1.35 / EA Pickles Sathers 4.25 oz. Sour Fruit Balls C $1.35 / EA Van Holten s 9.6 oz. Dill Pickle K G S $1.25 / EA 381 Sathers 4 oz. Gummy Bears $1.50 / EA Van Holten s 9.6 oz. Hot & Spicy Pickle K G $1.25 / EA 383 Sathers 4 oz. Sour Neon Worms $1.50 / EA Cheese Cactus Annie s 2 oz. Cheddar Cheese Squeeze Snack G $1.05 / EA 2586 Sathers 6 oz. Red Licorice Twists C $3.90 / EA Cactus Annie s 2 oz. Jalapeno Cheese Squeeze Snack G $1.05 / EA 2585 Skittles 2.17 oz. Original G $1.35 / EA 984 City Cow 4 oz. Nacho Cheese Dip with Jalapenos C R G $2.20 / EA 2858 Snickers 1.86 oz. Bar K $1.35 / EA Meat Snacks Twix 1.79 oz. Chocolate Caramel Cookie Bars K $1.35 / EA 799 Brushy Creek.78 oz. Single Serve Bacon (6 slices) $4.50 / EA 3609 Zero 1.85 oz. Bar K $1.35 / EA 987

4 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY O Briens 1.13 oz. Beef Sticks Hickory Smoked G $1.45 / EA 5379 Ramen Seafood Maruchan 3 oz. Beef Flavor Ramen C $0.85 / EA 9 Fresh Catch 3.53 oz. Fillets of Mackerel in Soybean Oil K H G $2.20 / EA 4385 Maruchan 3 oz. Cajun Chicken Flavor Ramen C $0.85 / EA 18 Fresh Catch 3.53 oz. Fish Steaks in Oil w/green Chiles K H G $2.00 / EA 4395 Maruchan 3 oz. Chicken & Mushroom Flavor Ramen $0.85 / EA 14 Fresh Catch 3.53 oz. Fish Steaks in Spicy Mustard Sauce K H G $2.10 / EA 4394 Maruchan 3 oz. Chicken Flavor Ramen C $0.85 / EA 8 Fresh Catch 3.53 oz. Sardines in Soybean Oil K H G $2.20 / EA 4388 Maruchan 3 oz. Chili Flavor Ramen C $0.85 / EA 10 Fresh Catch 4.23 oz. Chunk Light Tuna in Water K H G $3.50 / EA 4317 Maruchan 3 oz. Texas Beef Flavor Ramen C $0.85 / EA 13 Ready-To-Eat Meals Maruchan Instant Lunch 2.25 oz - Cajun Shrimp $1.30 / EA 5 Brushy Creek oz. Beef Stew G $3.75 / EA 1715 Maruchan Instant Lunch 2.25 oz. - Beef $1.30 / EA 2 Brushy Creek oz. Chili No Beans $3.50 / EA 1710 Maruchan Instant Lunch 2.25 oz. - Chicken $1.30 / EA 1 Brushy Creek oz. Chili with Beans G $3.50 / EA 1711 Noodles Brushy Creek oz. Chili with Beans Hot! G $3.50 / EA 1712 Velveeta 3 oz. Macaroni and Cheese K H C $1.90 / EA 4935 Brushy Creek 4.5 oz. Premium Chicken Breast G S $4.60 / EA 5360 Velveeta 3 oz. Spicy Macaroni and Cheese K H C $1.90 / EA 4936 Hormel 2.5 oz. Spam Single G S $4.00 / EA HEALTH & BEAUTY Rice Velveeta 2 oz. Cheesy Rice K H C $1.35 / EA 4937 Shampoo Crawford 4 oz. Balsam & Protein Shampoo C $1.40 / EA Velveeta 2 oz. Spicy, Cheesy Rice K H C $1.35 / EA 4938 Crawford 4 oz. Dandruff Shampoo C $1.40 / EA Beans Elementz 15 oz. Thickening Shampoo w/aloe & Ginseng $2.90 / EA Velveeta 4 oz. Cheesy Refried Beans K H C $3.20 / EA 4939 Conditioner Velveeta 4 oz. Spicy, Cheesy Refried Beans K H C $3.20 / EA 4940 Crawford 4 oz. Balsam & Protein Conditioner C $1.05 / EA Velveeta 4 oz. Spicy, Cheesy Refried Beans & Rice K H C $3.20 / EA 4941 Elementz 15 oz. Hydrating Conditioner Almond/Shea $2.60 / EA Tortillas Cactus Annie s 8 oz. Flour Tortillas (6 Pk.) K C R $2.50 / EA 5070 Ethnic Hair Care Dark & Lovely Conditioning Relaxer System $8.55 / EA 22661

5 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY Softee 5 oz. African Crown Hair Dress $2.75 / EA NewDay 3.75 oz. Petroleum Jelly C $4.50 / EA Softee 5 oz. Hair Food $3.25 / EA NewDay 4 oz. Baby Powder $1.75 / EA Sulfur8 2 oz. Medicated Original Conditioner $5.05 / EA No Rub 12 oz. Saline Solution $8.93 / EA Sulfur8 7.5 oz. Medicated Shampoo $5.05 / EA Tolnaftate.5 oz. Antifungal Cream $2.60 / EA Styling Products & Accessories Deodorant 5 Black Comb $0.28 / EA Lady Speed Stick Invisible Dry 1.4 oz. Anti-Perspirant Shower Fresh $4.60 / EA Elementz 15 oz. Styling Gel w/aloe Vera $3.55 / EA Palm Brush (Plastic) $0.80 / EA Pony-O s (1 ea.) $0.55 / EA Soap Dial 3.5 oz. Soap (1 Bar) $1.60 / EA Next1 5 oz. Anti-bacterial Sport Soap (1 Bar) C $1.40 / EA Lotion Crawford 4 oz. Cocoa Butter Lotion C $1.35 / EA Crawford 4 oz. Skin Care Lotion C $1.35 / EA Heritage 4.5 oz. Skin Cream Facial Cleanse $2.35 / EA Jergens 3 oz. Ultra Healing Lotion $3.75 / EA Pro Glo 4 oz. Cocoa Butter Cream w/aloe $2.55 / EA Skin Care Chapstick Regular.15 oz. $2.55 / EA Heritage 3 oz. Medicated Anti-Fungal Powder $3.60 / EA Hydrocortisone Cream.5% 1 oz. Tube $2.60 / EA Power-Up 2.5 oz. Clear A/P Deodorant - Force C $2.85 / EA Power-Up 2 oz. A/P Deodorant - Bloom C $2.50 / EA Speed Stick 3 oz. Ultimate Sport A/P Deodorant $4.00 / EA Dental Care Colgate 2.5 oz. Great Flavor Anticavity Toothpaste $2.75 / EA Cool Wave 4 oz. Fresh Mint Fluoride Toothpaste C $1.80 / EA Effergrip 2.5 oz. Cream Tube $6.05 / EA Freshmint Denture Tablets (40 Ct.) $3.28 / BX NWI Security Toothbrush $0.80 / EA Percara 8 oz. Oral Health Rinse Mouthwash $2.00 / EA Shaving Products Magic Cream 6 oz. Depilatory $5.30 / EA Pro-Tection 7 oz. Shave Cream $2.60 / EA Pro-Tection Twin Blade Disp. Razors (1 Pk.) C $0.40 / EA Women s Hygiene Massengill 4.5 oz. Vinegar & Water Douche $6.00 / EA Maximum Strength 1 oz. Acne Treatment Cream $3.30 / EA 26177

6 ITEM DESCRIPTION ITEM # Size QTY ITEM DESCRIPTION ITEM # Size QTY Playtex Gentle Glide Tampons (20 Pk.) $7.00 / BX Preference Panty Shields (22 Pk.) $3.05 / EA Pharmaceuticals Goodsense 2 oz. Hemorrhoidal Ointment $4.00 / EA Halls Regular Flavor Cough Drops (9 Ct.) $2.15 / EA Rolaids Regular Strength Antacid (1 Roll) $1.30 / EA CLOTHING & ACCESSORIES Indera Mills Thermal Long Sleeve Shirt - Natural Small, Medium, Large, XL, 2XL $6.75 / EA Indera Mills Thermal Long Sleeve Shirt - Natural 3XL, 4XL $8.50 / EA Socks Tube Socks - White (1 Pair) $1.80 / EA SHOES Casual Shoes Bob Barker Slip On Shoe - Navy M 6=W 7.5 $10.00 / EA T-Shirts Andrew Scott Crew Neck T-Shirt - White (1 Pk.) Small, Medium, Large, XL $3.75 / EA Robinson Slip On Navy Shoe 8, 9, 10, 11, 12, 13 $10.00 / EA Shoe Corp Leather Velcro Shoes 9, 10, 11, 12 $17.15 / EA Andrew Scott Crew Neck T-Shirt - White (1 Pk.) 2XL $4.50 / EA Andrew Scott Crew Neck T-Shirt - White (1 Pk.) 3XL $5.50 / EA Men s Underclothing Andrew Scott Men s Boxers - White (1 Pk.) Small, Medium, Large, XL, 2XL $4.25 / EA Andrew Scott Men s Boxers - White (1 Pk.) 3XL $6.25 / EA Andrew Scott Men s Briefs - White (1 Pk.) Small $2.50 / EA Andrew Scott Men s Briefs - White (1 Pk.) Medium, Large, XL, 2XL Women s Underclothing $3.00 / EA Hanes Her Way Cotton Briefs - White (3 Pk.) 6, 8, 10, 11 $4.00 / EA ELECTRONICS Radios GPX R2825 Clear AM/FM Radio C $22.00 / EA Batteries Ion 3 AA Batteries (4 Pk.) $3.00 / PK Ion 3 AAA Batteries (4 Pk.) $3.00 / PK Earbuds Koss KE5K- 4 Earbuds $5.50 / EA THE GENERAL STORE Stationery #10 Envelope $0.15 / EA Manhattan Hosiery Sports Bra - No-Wire (White) Small-32, Medium-34, Large-36, XL-38 $7.00 / EA No Clasp Envelope 9.5 x 12.5 $0.30 / EA Thermals Security Pen 1 Ct. (Black) $0.75 / EA Indera Mills Thermal Ankle-Length Drawers - Natural Small, Medium, Large, XL, 2XL $6.75 / EA White Paper Pad 8.5 x 11 (50 Sheet Pad) $1.60 / PAD Indera Mills Thermal Ankle-Length Drawers - Natural 4XL $8.50 / EA Art Supplies

7 ITEM DESCRIPTION ITEM # Size QTY Sketch Pad 8.5 X 11 (50 Sheet Pad) $1.80 / PAD Games Aviator - US Playing Cards $2.89 / EA Checkers Set with Board $8.50 / EA Chess Set with Board $7.59 / EA Double Six Dominoes $6.00 / EA Dictionaries Webster s New Pocket Dictionary $2.05 / EA Towels Wash Cloth 12 X 12 (White) $1.00 / EA White Cotton Bath Towel 20 x 40 $5.00 / EA Miscellaneous Cereal Bowl w/lid 24 oz. $2.00 / EA ITEM DESCRIPTION ITEM # Size QTY NON- TAXABLE ITEMS THE GENERAL STORE Stationery #10 Stamped Envelope $0.70 / EA 983 Stamps (Book of Ten) $4.90 / CS 928 Greeting Cards Anniversary Card w/stamp $2.90 / KIT Birthday Card w/stamp $2.90 / KIT Get Well Card w/stamp $2.90 / KIT Juvenile Birthday Card w/stamp $2.90 / KIT Seasonal Greeting Card w/stamp $2.90 / KIT Thank You Card w/stamp $2.90 / KIT TAXABLE SUB Contact Lens Case $1.28 / EA 2077 Disposable Earplugs $0.85 / EA Hinged Soap Dish (Soap Not Included) C $1.05 / EA Mesh Orange Laundry Bag 24 x 36 $5.00 / EA Plastic 22 oz. Tumbler (w/lid) $1.05 / EA Sharkeyes Reading Glasses 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75 $5.75 / EA Toothbrush Holder (Toothbrush Not Included) $0.80 / EA Faith Items Holy Bible $20.00 / EA 2174 Holy Qur an $32.00 / EA

8 SHIP TO: Inmate s Name Institution/Dorm/Housing# Street Address City State Zip SENDER: Sender s Name Street Address City State Zip Phone Number We cannot send orders from one inmate to another. (You will receive confirmation s when the order is shipped and received.) ID# REQUIRED for order fulfillment. CALCULATE AMOUNT DUE: TAX S Taxable: x 1.10 = Non-Taxable: x 1.00 = Processing Fee: $5.95 x 1.10 = $6.65 AMOUNT DUE: SELECT PAYMENT METHOD: Cashier s Check Money Order Make check or money order payable to ACCESS SECUREPAK VISA MasterCard Discover Cardholder Name Cardholder Signature Daytime Phone Number / / Today s Date mm/dd/yyyy PROGRAM DATES: Ordering Begins: March 20, 2017 Delivery to facility: Every Tuesday and Friday WAYS TO ORDER Online: alabamapackages.com Phone: Mail: Access Securepak (AL), Linpage Place St. Louis, MO Fax: ACCEPTABLE FORMS OF PAYMENT: Credit/Debit Cards VISA, MasterCard, Discover Prepaid cards that have a verifiable United States address Cashier s check Money order We do not accept personal checks and will return them to the sender. Credit/debit and prepaid cards will be charged on the day the order is placed. Refunds or credits will be applied to the card used for the order (allow additional time for refunds/credits on prepaid cards). Access Securepak reserves the right to remove one or more items from the order due to insufficient payment. SALES TAX: Access Securepak is required by the state of Alabama to collect 10% sales tax on all merchandise in the taxable section of the order form including the processing fee. Please see the tax calculation example below for more information. Tax calculation example: $87.50 taxable items total x 1.10 (tax rate) = $96.25 taxable items subtotal $15.35 non- taxable items total x 1.00 (tax rate) = $15.35 non- taxable items subtotal $4.00 processing fee x 1.10 (tax rate) = $4.40 processing fee subtotal $96.25 taxable items subtotal + $15.35 non- taxable items subtotal + $4.40 processing fee subtotal = $ total due ELIGIBILITY: Access Securepak verifies inmate eligibility before shipping packages, if applicable. LIMITS: There is no spending limit. CATALOG CHANGES: Every effort has been made to show and describe the merchandise as accurately as possible. Because many manufacturers change an item s design, color, package size and style after our catalog is produced, we reserve the right to discontinue or change product specifications without prior notice. We regret any changes that might occur and will make every effort to minimize these occurrences. Inadvertent errors in product descriptions, pricing and special offers are not binding on Access Securepak, and we may make adjustments at any time. Additionally, many of our food items may contain common allergens such as milk, eggs, wheat and peanuts. Before consuming a food item, please consult the product packaging for specific information on its ingredients. Prices and offers are subject to change and available while supplies last. Always consult the alabamapackages.com website for the latest updates on this package program. In the event of a back order, may we substitute like items of equal or greater value? Note: unless you choose NO, we may substitute for out-of-stock or restricted items. _YES _NO CUSTOMER SERVICE: alabamapackages.com Automated system is available 24 hours a day, seven days a week Live bilingual representatives are available Monday through Friday, 7:30 a.m. 11:00 p.m. CST, and Saturday, 10 a.m. 4 p.m. CST. Credit Card Number / Expiration Date Security Code Security code is last three digits of account number panel.

Order Form Sunflower County Effective May 2018 Please complete all info on reverse (print clearly).

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