Fax Order Form - PepperJax Grill
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Fax Order Form 1 2 Call 785.856.4529 to confirm your order 919 Massachusetts Street | Lawrence, KS 66044 | phone 785.856.4529 | fax 785.856.7529 Start Here ____/____/____ Please Print Date __________________________ Company Name Complete the order form below. 3 __________________________ 4 Contact Name Fax your order to 785.856.7529. _____-_____-_______ __________ Phone Pick Up Time ____ of ____ Page Call 785.856.4529 to confirm your order. No need to wait in line. Go right to the register. Your order will be ready for you. We would appreciate orders of five or more (Share What You Crave!) and one form of payment - Cash, American Express, Visa, Mastercard or Discover. NAME SPECIAL INSTRUCTIONS ITEM WITH CIRCLE ONE CIRCLE ONE GRILLED VEGGIES RICE & BEANS STEAK CHCK SHRIMP VEG ONION MUSH GREEN JALP PEPPER 1 2 3 4 5 6 7 8 9 10 Example Tomatoes, Cheese Ranch on Salad SALSA MILD SHRED CHEESE DELI TOPPINGS RICE BLACK PINTO HOT LET TOM BLACK SOUR RANCH SPICY OLIVE CREAM RANCH PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA PHILLY RICE BOWL BURITTO NACHOS SALAD S C SH V O M GP J RI B P H M CH L T BO SC RA SRA SIDE ORDERS DRINK SPECIFY CHOICE PLEASE WRITE FLAVOR AND SPECIFIC TYPE Side Salad Diet Pepsi Bole * All phillies come with cheese unless requested otherwise. Light or no seasoning available upon request. FAMOUS PHILLIES GOURMET RICE BOWLS Steak ..................... $6.59 Steak ..................... $6.99 Chicken ................ $6.49 Chicken ................ $6.89 Vegetarian ........... $5.69 Shrimp....................$7.49 Vegetarian ........... $6.09 DRINKS Soft Drink (Pepsi products) $1.99/$2.19 GIANT BURRITOS LOADED NACHOS FRESH SALADS Steak ..................... $6.69 Steak...................... $7.99 Steak ..................... $6.79 Chicken ................ $6.59 Chicken................. $7.79 Chicken ................ $6.69 Shrimp....................$7.19 Vegetarian ........... $5.99 Shrimp....................$7.29 Vegetarian............ $5.79 Vegetarian ........... $5.89 Iced Tea $1.99/$2.19 Bottled Drink $2.09 Milk (White or Choc) $1.29 SIDE ITEMS Queso & Dip Chips ...$3.59 Salsa & Dip Chips ......$1.99 Dip Chips.........................$.99 Queso...............$2.59/$1.29 Beans & Rice .............. $2.19 French Fries ................ $2.19 Side Salad ................... $2.19 Chips................................ $.99 Cookies ........................... $.99 Mandarin Oranges ...... $1.39 www.PepperJaxGrill.com
