Flower Delivery Request
To FAX:
 Complete this form, print it, sign it,
and then FAX it to:
(519) 396-8679
Call us toll-free at: 1-800-465-3215 to make payment arrangements, confirm order details, or place order by telephone.

1) Please complete the following information about yourself:

Name
Address City
Province / State Postal / Zip code Country
Phone number () - - FAX number: () - -
E-mail address:

2) Please complete the information about the delivery:

Name
Address City
Province / State Postal / Zip code Country
Phone number () - - FAX number: () - -
E-mail address:
Delivery Date:


3) Please enter your Salutation and Card Message:

Salutation:
Card Message:

4) What may we send for you ? :

Specific Arrangements:
Items # , # , # , # ,
Or
Designer's Choice
PRICE: $ (Canadian Dollars) Delivery charges and Taxes will be added on.

Any Special Instructions:

5) Your credit card information:

Card type VISA Master Card American Express
Diner's Club Discover EnRoute
Card number Expiry date
Card holder name Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _
Note: For security of your credit card information, we accept orders by FAX or phone rather than via online transactions. Seasonal and regional conditions affect the supply of flowers. Specific varieties or colours may not always be available. In come cases, substitutions may be necessary.

Thank you for your order!