SECTION 1 – Customer Information
Name:	VDOF Use Only
Address:	RT No.: (if applicable)
City:	State:	Zip:	Order No.:
Delivery Place:	Order Date:
Residential Address	Business Address	Matched By: (if applicable)
Requested Delivery Date:	Date Delivered:
Home Phone:	Work Phone:	Tract No.:
E-mail:
Type of Ownership:	Private Landowner	Forestry Industry	Other Industry	Received By:
State Agency #	Federal	County or City	Log/Receipt No.:
Other	Date:
Purpose of Planting:	Forestation	Erosion Control	Windbreaks	Amount:
Christmas Trees	Other	CD/DT No.:
County Where Tree Will Be Planted:
SECTION 2 – Order Information
Quantity Needed	Description (Kind of Trees, Seed or Package)	Price Per 1000	Total Cost	Cost Matched	No. Trees Matched
Loblolly Pine, Premium (OP)	$90.00
Subtotal:
Sales Tax (5.3% of Order Subtotal) [Tax-exempt orders must submit a completed sales tax exemption (i.e. ST-18; blank sales tax exemption forms can be found at tax. Virginia.gov).]
Less Matched Seedlings
Total Amount Due (Payment must be enclosed at the time of order):
SECTION 3 – Payment Information
Make check payable to "State Forester". No refunds after May 1st. A $20.00 service charge will be applied to all refunds except those caused by the nurseries' inability to deliver ordered seedlings. If seedlings do not arrive in good condition, (i.e. dry, damaged or diseased), claims must be made by telephone or in writing within 7 days of receipt. All unsatisfactory or rejected goods must be held for our advice or disposition. It is agreed between the purchaser and the Department of Forestry that our liability will not exceed the original purchase price of the product. The Department of Forestry assumes no responsibility or liability for the planting of any tree seedlings and in the sale thereof, makes no warranties, expressed or implied, of merchantability or fitness for a particular purpose and makes no warranties regarding the survival or rate of growth of any seedlings.
SECTION 4 – Reforestation Services Agreement	(Check the reforestation services you wish to obtain from the VA Department of Forestry)
Seedling Delivery	@ $	Per Loaded Mile	$	Min.	SSN/FIN:
Planting Coordination	@ $	Per Acre	$	Min.
I agree to designate and assume responsibility for boundaries of the tract where service work is to be performed. I agree to pay the Department of Forestry for the requested products and/or services within 30 days of receipt of a statement after services are rendered. If payment is not received within 30 days, I will be subject to a late payment fee of 10% per annum. In addition, if the matter is referred for collection, I will be liable for an additional 20% of the unpaid balance.
Name (Print)	Signature	Date