Billing Information (Name as it appears on Credit Card)

First Name: Middle Initial: Last Name:

Billing Address: ............................. City: State: Zip Code:

......... Phone Number:( ) - E-mail Address:

Delivery Information

Delivery Date:

First Name: Last Name:

Delivery Address: ............................. City: State: Zip Code:

......... Phone Number:( ) -

Credit Card Information

Mastercard American Express Discover

Credit Card Number: Exp. Date:

Product Information

Product Code: ............. Price: ...............Flower Request or Color Specification:

Would you like a card enclosed?.......................................................

No

Saying:

Please select if you would like any of the following included:

1/2 lb. Box of Kara Chocolates ($7.99) . 1 lb. box of Kara Chocolates ($13.99)
Mylar Balloons ($3.00 each) Plush Boyds Bears ($15.99 and up)

Additional comments:

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................ .........

(Substitutions of flowers and/or color may be necessary. We will do our best to keep the same look, style, and value.)

Please call us directly if you have any questions or concerns. (208) 888-2414

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