Customer Information
Name.....
Address..
City........ State .. ZIP..
Phone..... Cell..


Delivery Information
Name.....
Address..
City........ State.. ZIP..
Phone.....

Favorite Colors:.....
Doesn't Like:.........

Dates____ and_______ Occasions to send flowers
1 $00.00 $35.00 $40.00v $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

2 $00.00 $40.00 $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

3 $00.00 $40.00 $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

4 $00.00 $35.00 $40.00 $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

5 $00.00 $35.00 $40.00 $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

6 $00.00 $35.00 $40.00 $45.00 $50.00 $55.00 $60.00 $65.00 $70.00 $75.00 $80.00 $85.00 $90.00 $95.00 $100.00 $125.00 $150.00 Choose Value (plus delivery $7.00 and tax)

What kind of Bouquet (watertubed and wrapped) or
Arrangement (In a vase) or live plant do you want?
Explain briefly.

Your expression on the card.

Special Instructions




Choose Payment Method Cash Check House Account Visa Master Charge American Express Discover Select One
( We will Call you for Credit Card Information to ensure security )

Pick up or delivery? Pick up Delivery Choose One