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Floral Art - Fax Order Form

Please complete the following form and Fax to +61 394840288

Phone: +61 039 4840262

1. Card Details

Would you also like a card?
No thank you
Free Complimentary Card or
Greeting Card ($2.00)
Other

2. Message Details

Enter your message below: (optional)

3. Your Details

Your Name:
Your Address:
Your Contact Number:
Your Email:

4. Delivery Details

Deliver To:

Address Details (Recipient Details) <% IF delNum >= 3 then %> <% end if if delNum >= 2 then %> <% end if %>
Name:  
Country:  
State:  
Suburb:  
Address:
Contact Number:

Pickup Delivery
Today or Specify Date:
AM (9-12pm) PM (12-5pm)

5. Extra Items
(optional)

Chocolates:
Teddy Bears:
Wine:
Balloons:

6. Order Details

Arrangement Name
Arrangement Price $ Free Delivery
Quantity  
Total To Be Charged: $

7. Payment Details

Credit Card
Card Number
Expiry Date
Name on Card

Account Customers (optional)

Account Code (Optional)
Enter your Code:

Fax this form to +61 39484 0288