Floral Glow - CDNB Divine Glow, Inc.
Telephone number:  905 896 2958    Fax number: 905 896 2958
E-mail   floralglow@bell.net



* First Name :  _______________________    * Last Name :    __________________________
            
Company Name ______________       Delivery Date required ____(Day)_____(Month)_______(Year)

 

* Phone No :(Home)______________ * Email address :  ______________________________

                        (Work) ____________________

                        (Cell) _____________________


                      Flower preferences    ________________    Color preference     __________________
                      First Choice                ________________    First Choice              __________________
                      Second Choice           ________________    Second Choice       __________________
                              None                (   )                   no specifics
                      Occasion
                                          (  )     Anniversary                  
                                          (  )     Baby Congratulations   
                                          (  )     Birthday                                                     
                                                        (  )      Wedding                                                                       
                                          (  )     Congratulations 
                                          (  )     Get Well 
                                          (  )     Graduation
                                          (  )     Easter greeting
                                          (  )     Sympathy 

                                          (  )     Others __________________________________________
 

A.   Price Point -                          Amount          PST                GST                Total
       Item .      ____________       ______            _______          _______             
       Item        ____________       ______            _______          _______
B.    Delivery charge                      ______                                     _______      ________
      


C.   Payment:  

       Visa  /   Master Card      No._________________________              

                                                                                  Expiry Date__________ MM/YY
       Name on the VISA/MASTERCARD  _________________________________ 

       Signature _____________________________

D.  Date of delivery ____________________  

      Name of Recipient _________________________

      Tel No. ___________________________
      Shipping Address ________________________________________________ (Street)

      ____________________ (City)______________(Province)___________(Postal Code)
      Message on the card ____________________________________________________

      _____________________________________________________________________

      Others _______________________________________________________________

      _____________________________________________________________________

 

 

SUBMIT