Bench Order Form                                               

Bench Page                       Home               

You can call in an order, or fax or mail this form to place an order.  If you have any question

or need help filling out the form, please call.


Phone:  605-665-2621


Address:      Countryside Mfg. Inc.

                    30793 435th Ave.

                    Yankton, SD   57078


Shipping Address:______________________________________________________



E-mail: ______________________________________________________________  

Daytime Phone: _______________________________

Payment Method:

Check_______ Money Order or Certified Check________ Credit Card________ PayPal_________

Credit Card Type:  (Circle One)           VISA              MASTERCARD              DISCOVER

Number:___________________________________   Exp. Date______________

Security Code - The last 3 digits in or close to the signature strip on back of card ___________

Name on card:______________________________________

Billing address of credit card if different from above:_________________________________________________


*All information will remain confidential and will not be given or sold to any other companies.


Type of Bench:      Deacon's Bench _______       Open ________


   Custom Size: _______________________ Please Call for Prices on Custom Sizes


Wood Balls:      Yes_______       No ________

Choose Type of Wood:

     Oak____________                Cherry_____________

      Walnut__________                Other:_____________

      Oak/Walnut Combination_____________

Cedar Lining:       Yes________       No________

The back of the storage area on the Deacon's Bench is flat. It can be ordered with Raised Panels and Trim Like the Front for additional cost. 


      No ________  

Choose Stain: (Circle One)


Walnut or Cherry:

Early American: Medium golden stain

Natural Walnut - may have light streaks

Provincial: Medium slightly reddish stain


Fruitwood: Light

Cherry Stain on Walnut

Natural Oak - very light

Natural Cherry

Dark Cherry


Etching Design:  Please write in etching design number  - 

Write in none if you don't want an etching

Design:__________________ Custom:__________________________

For custom designs, please include any special instructions below.

Do not fax designs, or images. Please scan these at 300-600 dpi and e-mail them or mail in the original. 

Originals will be returned with the order. See the Photo Information page for more directions.


Special Instructions:





Please fill in Item #, Description, & Quantity. Leave the Price blank if you want us to figure the cost.

Item #





Ground Shipping Charges will be added based on weight & distance. If you want a shipping price, please call or email us for a quote.

Please call for pricing on other types of wood or custom sizes

Credit card will not be charged until the bench ships.

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