The Gift Basket

FAX  TO:   (519) 451-0843

REQUESTED BY:

Your Name ____________________________________________________________________________________

Address _______________________________________________________________________________________

City__________________________________________Province/State__________Postal Code/Zip____________

Phone:  Day: (______ )__________________________ ext__________ Eve/Cell: (______)___________________

E-mail ____________________________________________________Fax: (______)_________________________

DESIGN CHOICE

Title____________________________________________________________________________________________

Amount $________________  (+ delivery)      Requested Delivery Date ___________________________________

VISA  OR   M/C    __   __   __   __   ∎   __   __   __   __   ∎   __   __   __   __   ∎   __   __   __   __     EXP __   __   ∎   __   __

Cardholder's Signature_______________________________________________________Date________________

DELIVERY INFORMATION

DELIVER TO:          ** NOTE:  If delivery information provided by you is incorrect, there will be additional charges for re-delivery. 

Name____________________________________________________________________________________________

Address__________________________________________________________________________________________

City________________________________________________________________Postal Code____________________

Home Phone____________________________________Alternate Ph.______________________________________

 GREETING / MESSAGE ON CARD TO READ:

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