The Gift Basket
FAX TO: (519) 451-0843
REQUESTED BY:
Your Name _____________________________________________________________________________________
Address _______________________________________________________________________________________
City___________________________________________Province/State_________Postal Code/Zip_______________
Phone: Day: (______ )__________________________ ext__________ Evening: (______)______________________
E-mail ____________________________________________________Fax: (______)_________________________
DESIGN CHOICE
Title___________________________________________________________________________________________
Amount $________________ (+ tax + delivery) Requested Delivery Date ____________________________________
VISA OR M/C __ __ __ __ ∎ __ __ __ __ ∎ __ __ __ __ ∎ __ __ __ __ EXP __ __ ∎ __ __
Cardholder's Signature_______________________________________________________Date___________________
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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