"Dine In"

Palace Pizza Bar & Grill

"Take Out"

FAX  ORDERS

     Name
Last.---------      Must be filled in to confirm ORDER
First.---------      Must be filled in to confirm ORDER
Mid.----------  

     Company (if ordering from a company)
Company.----------------  
Department.-------------  
Company Phone #.---      Must be filled in to confirm ORDER

     Address
Street.-------  
City.----------  
State.--------      Zip.-------  
E-Mail. ------  
Phone #.---       Must be filled in to confirm ORDER
Fax #.-------       Must be filled in to confirm ORDER
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Ordering Information     Please fill in your order the way you want it.
(all orders will be made the way we receive them.)     (There are 19 ordering lines "ONLY".) Please print out this page and Fax it to ---> (610)433-8191 Thank you for your Fax Order