Please print this form, complete it, and then fax the completed form
to 1-207-641-0867. Please print clearly.

Person Ordering

Name:
Address:
Town: State: Zip Code:
Home Phone#: Work Phone#:

Person Who Is Receiving the Delivery

Name:
Address:
Town: State: Zip Code:
Home Phone#: Work Phone#:

Order Information

Type of Arrangement (circle one)

Vase Arrangement
(minimum $35)

Tied Bouquet
(minimum $25)

Plant
(minimum $25)

Other (describe)

Desired Colors
(circle one)

Whites

Brights

Pastels

Other (describe)

Price Range of Arrangement: $
Tax & delivery charge are added to the arrangement cost.  Local deliveries (within 2 miles) are free.  Deliveries made beyond 2 miles are charged a minimum of $4.50.
Please provide a description of what you would like delivered.  *Market fluctuations affect the availability of specific flowers.  We will do our best to accommodate your request.*

 

 

 

 

The card should read:

 

 

Credit Card Information

Credit Card (circle one)

Visa

Master Card

American Express

Name on Credit Card:
Card#: Expiration Date:

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