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1.Select Product Type—Please choose an option—Premium Subscription BoxPremium Okie Joe Coffee Subscription Box

2.Choose Subscription Type* —Please choose an option—Monthly Premium Subscription Box - $35/mo + $3.95 handling fee3-Month Premium Subscription Box - $99.95 + $11.85 handling fee6-Month Premium Subscription Box - $199.95 + $23.70 handling fee12-Month Premium Subuscription Box- $399.95 + $45.00 handling fee

3.Are You* FemaleMale

4.Your Name*

5.Email Address*

6.Phone Number*

7.Billing Address*

8.Shipping Address (Optional)




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Add Preferences (Optional)

9.When is your birthday?

10.What is your t-shirt size? SmallMediumLargeExtra LargeXXL

11.What is your favorite color? BluesRedsYellowsGreens

12.Would you like to sign up to be a beta tester for future products? YesNo

13.Check all that applies to you
* Age Under 21Age 21-30Age 31-49Age 50+

14. Select coffee options Dark Roast CoffeeMedium Roast CoffeeEitherNone

Choose Payment Option* —Please choose an option—Credit CardBank

15.Add Credit Card Details*

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Expiration Date*
CVV*

16.Add Bank Details (If Card Details Are Not Added)

Bank Name
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Account Type—Please choose an option—CheckingSavings

Promo Code

[group MonthlyCond] Authorization* I authorize Sample Oklahoma Company, “wholesale.sampleoklahoma.com” to initiate an electronic charge to my bank account or credit card in the amount stated above + sales tax and a $3.95 recurring handling fee. Charges would occur based on the frequency of the subscription terms.
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[group ThreeM0nths] Authorization* I authorize Sample Oklahoma Company, “ wholesale.sampleoklahoma.com ” to initiate an electronic charge to my bank account or credit card in the amount stated above + sales tax and a $11.85 handling fee. Charges would occur based on the frequency of the subscription terms.
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[group SixM0nths] Authorization* I authorize Sample Oklahoma Company, “ wholesale.sampleoklahoma.com ” to initiate an electronic charge to my bank account or credit card in the amount stated above + sales tax and a $23.70 handling fee. Charges would occur based on the frequency of the subscription terms.
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[group TwelveMonths] Authorization* I authorize Sample Oklahoma Company, “ wholesale.sampleoklahoma.com ” to initiate an electronic charge to my bank account or credit card in the amount stated above + sales tax and a $45.00 handling fee. Charges would occur based on the frequency of the subscription terms.
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For questions, you may email us at support@sampleok.com

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