Order Test Form

Order & Delivery Information form:

Recipients Name:

Delivery Date:

Delivery Information:

Home address:

Work address and name of the company

City:

Zip Code:

State:

Phone numbers:

Home:

Work:

Cell:

Any special delivery instructions:

Order Description: (please indicate your choice)

Dozen Roses

Color:

Vase

Basket

Mix Flowers Bouquet

Plant

Bouquet of Balloons

Gourmet Baskets

Fruit Basket

Cookie Basket

Munchies Basket

Baby Basket

Desire message on the card:

Personal Information:

Sold to y/or sender's name and E-mail address (If you wish to be contacted by e-mail only, please submit your e-mail.)

Name:

E-mail:

Your daytime phone number and evening phone number: (Note: Some areas require an additional $5.00 per delivery charge. All changes in prices will be verified by phone.)

Daytime:

Evening:

Payment information: (When ordering please have this information ready )

We accept credit cards. (Please indicate credit card type, account number and expiration date)

Visa

Master Card

American Express

Discover

Acct.#

Expiration Date:

(Sales tax and delivery charges will be added to your order)

Any comments:

End of order page. >>>Thank you for ordering at Glorias Blossoms Flowers Shop. Have a great day!

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