Purchase Order Brochure

DEPARTMENT OF FINANCIAL SERVICES
Division of Funeral, Cemetery & Consumer Services
200 East Gaines Street
Tallahassee, FL 32399- 0361

Purchase Order

BROCHURE

This form is for use in purchasing the Board of Funeral, Cemetery and Consumer Services Brochure regarding cemetery and preneed sales

REQUIRED FEE: $7 per 100 (must accompany this form)

Make checks payable to the Department of Financial Services

PRINT OR TYPE CLEARLY.

Section 1. NAME & ADDRESS

Firm Name:

/ Contact Person:
First Name: Last name:
Mailing address:
City: / State: / Zip:
Telephone Number: () - / Email:
Total number of brochures requested: @ $7 per hundred = $
Shipping $5.00 for the first 100, $1.50 for each additional 100 $
Total Remitted $

Mail completed purchase order and required fee to:

Division of Funeral, Cemetery & Consumer Services

Revenue Processing

P.O. Box 6100

Tallahassee, FL 32314-6100

FOR OFFICE USE ONLY:
BT TYCL FT
V 4001 W $7.00 per hundred plus shipping

Form DFS-N1-1729 – Purchase Order Brochure

(Rev. 08/12); 69K-1.001 Page 1 of 1