Pizza Hut Pan Glo Pan Cleaning Form

							                   Pizza Hut & Pan Glo Pan Cleaning Form
Franchise/Company Name:                                                                                  Store #:

Complete Store Address:

City :                                                                                   State:             Zip:

Daytime Phone #:                  Area Code (        )                                 Fax #:     Area Code (       )

Email Address:

MINIMUM ORDER $50.00                        (Not including shipping and handling costs.)

                       Pan Type                                    Quantity              Clean         Straighten               Total

              12" Thin Crust - Perforated                                            $1.25            $0.50

              14" Thin Crust - Perforated                                            $1.25            $0.50

     12" Deep Dish - Hard Anodized (Dine-In)                                         $1.75            $0.50

         12" Deep Dish - Plain Anodized (Delco)                                      $1.75            $0.50

     14" Deep Dish - Hard Anodized (Dine-In)                                         $1.75            $0.50

         14" Deep Dish - Plain Anodized (Delco)                                      $1.75            $0.50

                      Bread Stick                                                    $2.25            $0.50

               Personal Pan Pizza (PPP)                                              $1.75            $0.50

                 12" Thin Crust - Solid                                              $1.25            $0.50

                 14" Thin Crust - Solid                                              $1.25            $0.50

                                                                                                                Total:




                      THIS COMPLETED FORM, ALONG WITH ALL PAN QUANTITIES, MUST BE
                     INCLUDED IN THE BOX WITH YOUR PIZZA HUT LOCATION INFORMATION.

                                      PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS.

Payment Method:                                          Credit Card Only ( Circle One) Master Card Visa Discover American Express
Credit Card Billing Information:
16 Digit Card Number:                                             __ __ __ __       __ __ __ __       __ __ __ __        __ __ __ __
Name as it appears on Card:
Credit Card Billing Address:
City/State/Zip:
Expiration Date (MM/YY):                                          __ __ / __ __
Authorized Signature:
                                                                                                                         PG/PizzaHut 10/05/2009