Customer Contact Information Form
This is for our records only. We promise not sell your information or fill up your inbox with emails.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Phone Type
*
Please Select
Cell/Mobile
Home/Landline
Email
*
example@example.com
Preferred Method of Communication
*
Please Select
Text
Phone
Email
Billing/Delivery Address
*
Street Address
Street Address Line 2/ Apt#
City
State / Province
Postal / Zip Code
Brief description of item being ordered
*
Desk, Kitchen table, Side table, Entry Bench, etc.
I have read and agree with the Terms and Conditions.
Pickup/Delivery
*
Please Select
Pickup from With the Grain-NC
Deliver to my home address
Free delivery within 15 miles. See Terms and Conditions for additional delivery fees.
Submit
Should be Empty: