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Wild Rose Co-op Killam Food Store Order Form
Hi there, please fill out and submit this form.
28
Questions
START
1
Delivery or Curbside pick up
Delivery
Curbside pick up
Delivery
Curbside pick up
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2
Name
*
This field is required.
First Name
Last Name
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3
Membership Number
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4
Phone Number
*
This field is required.
Area Code
Phone Number
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5
Email
example@example.com
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6
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
Delivery Date
*
This field is required.
In order for same day delivery, you must submit your order by 11:00am that day.
-
Date
Year
Month
Day
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8
Allow Substitutions?
*
This field is required.
If a requested item is out of stock, would you like us to substitute another brand? We will default to Co-op brand products when substitution is required. If you request no substitutions, unavailable items will be removed from your order.
YES
NO
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9
Produce Department
These are items such as: Fresh fruit, vegetables, refrigerated salad dressings, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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10
Any additional Produce Items or Special Instructions
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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11
Dairy Cooler Items
These are items such as: Cheese, butter and margerine, eggs, milks, coffee creamer, dips.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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12
Any additional Dairy Cooler Items, or Special Instructions
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Submit
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Enter
13
Meat Department
These are items such as: Fresh Meats, packaged deli meats, hot dogs, smokies, beef jerky, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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Enter
14
Additional Meat Department Items, or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Submit
Press
Enter
15
Grocery Items
These are items that are typically in the inner aisles of the store. For example soups, noodles, cereals, baking items, snacks, crackers, spices, sauces, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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16
Grocery Items
These are items that are typically in the inner aisles of the store. For example soups, noodles, cereals, baking items, snacks, crackers, spices, sauces, etc.
Item Name
Quantitiy
Size/Brand/Description
6
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
7
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
8
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
9
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
10
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
6
7
8
9
10
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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17
Additional Grocery Items, or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Submit
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Enter
18
Frozen Department
These are items such as: Frozen fruit, and vegetables, meals, meats, juices, ice cream novelties, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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19
Additional Frozen Items or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Enter
20
Bakery Department Items.
These are items such as: Bread, buns, muffins, cakes, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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21
Additional Bakery Items or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Enter
22
Deli Department Items.
These are items such as: Deli Meats, speciality cheese, dips, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
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23
Additional Deli Items or Special Instructions
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Enter
24
Household Items
These are items such as: Cleaning supplies, paper products, personal hygeine items, etc.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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25
Additional Household Items, or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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26
Misc Items
This is for any items you feel doesn't fit anywhere else.
Item Name
Quantitiy
Size/Brand/Description
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item Name
Row 0, Column 0
Quantitiy
Row 0, Column 1
Size/Brand/Description
Row 0, Column 2
Item Name
Row 1, Column 0
Quantitiy
Row 1, Column 1
Size/Brand/Description
Row 1, Column 2
Item Name
Row 2, Column 0
Quantitiy
Row 2, Column 1
Size/Brand/Description
Row 2, Column 2
Item Name
Row 3, Column 0
Quantitiy
Row 3, Column 1
Size/Brand/Description
Row 3, Column 2
Item Name
Row 4, Column 0
Quantitiy
Row 4, Column 1
Size/Brand/Description
Row 4, Column 2
1
of 5
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27
Additional Items, or Special Instructions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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28
Payment Options
We are currenlty only accepting Debit or Credit Cards at the door for Payment.
Debit Card
Credit Card
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Wild Rose Co-op Killam Food Store Order Form
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