FAX ORDER FORM

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: (______)_________________________

PAYMENT METHOD □ VISA □ M/C

Card Number __ __ __ __ ∎ __ __ __ __ ∎ __ __ __ __ ∎ __ __ __ __ EXP __ __ ∎ __ __

Cardholder's Signature_______________________________________________________Date_______________

DESIGN CHOICE

Title__________________________________________________________________________________________

Amount $________________ (+ delivery) Requested Delivery Date _________________________________

DELIVERY INFORMATION

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

We call ahead before a delivery and require a signature.

Name____________________________________________________________________________________________

Address__________________________________________________________________________________________

City________________________________________________________________Postal Code____________________

Home Phone____________________________________Alternate Ph.______________________________

GREETING / MESSAGE ON CARD TO READ:

__________________________________________________________________________________________________

______________________________________________________________________________________