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PLEASE
PROVIDE THE FOLLOWING INFO: |
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PURCHASER
INFORMATION: |
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Contact
Name |
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Contact
last name |
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Florist
Name |
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Address |
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City |
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State/Province |
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Zip/Postal
Code |
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Country |
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Business
Phone |
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Home
Phone |
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Cell
Phone |
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E-mail |
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RECIPIENT
INFORMATION: |
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CLICK
IF SAME AS PURCHASER AND SKIP THIS SECTION |
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Full
Name |
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Address |
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City |
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State/Province |
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Zip/Postal
Code |
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Country |
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Business
Phone |
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Home
Phone |
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Cell
Phone |
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E-mail |
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BI
COLORS ROSES SELECT TYPE, SIZE AND QTY - EACH BUNCHE
CONTAINS 25 ROSES |
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AMBIANCE: |
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QTY.
BUNCHES: |
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BELLA
VITA: |
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QTY.
BUNCHES: |
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BIG
FUN: |
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QTY.
BUNCHES: |
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BLUSH: |
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QTY.
BUNCHES: |
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CANDIA: |
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QTY.
BUNCHES: |
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CARAMELLA: |
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QTY.
BUNCHES: |
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CARNAVAL: |
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QTY.
BUNCHES: |
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CARROUSEL: |
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QTY.
BUNCHES: |
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CHANSON: |
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QTY.
BUNCHES: |
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CHERRY
BRANDY: |
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QTY.
BUNCHES: |
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CIRCUS: |
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QTY.
BUNCHES: |
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CLASSIC
CEZZANE: |
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QTY.
BUNCHES: |
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DOLCE
VITA: |
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QTY.
BUNCHES: |
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ELENA: |
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QTY.
BUNCHES: |
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ESPERANCE
(x 12 STM): |
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QTY.
BUNCHES: |
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FANCY
AMAZON: |
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QTY.
BUNCHES: |
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FASHION: |
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QTY.
BUNCHES: |
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FIRE
AND ICE: |
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QTY.
BUNCHES: |
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FRIENDSHIP: |
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QTY.
BUNCHES: |
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GELATO: |
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QTY.
BUNCHES: |
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GOSPEL: |
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QTY.
BUNCHES: |
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GIPSY
CURIOSA: |
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QTY.
BUNCHES: |
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HARMONY: |
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QTY.
BUNCHES: |
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HELIO: |
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QTY.
BUNCHES: |
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HOCUS
POCUS: |
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QTY.
BUNCHES: |
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JULIA: |
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QTY.
BUNCHES: |
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KONFETTI: |
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QTY.
BUNCHES: |
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KONTIQUI: |
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QTY.
BUNCHES: |
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LAGUNA: |
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QTY.
BUNCHES: |
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LATIN
BEAUTY: |
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QTY.
BUNCHES: |
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LATIN
CIRCUS: |
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QTY.
BUNCHES: |
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LATIN
LADY: |
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QTY.
BUNCHES: |
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LEONIDAS: |
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QTY.
BUNCHES: |
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LIPSTICK: |
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QTY.
BUNCHES: |
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LUXOR: |
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QTY.
BUNCHES: |
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MALIBU: |
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QTY.
BUNCHES: |
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MIRAGE: |
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QTY.
BUNCHES: |
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NICOLE: |
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QTY.
BUNCHES: |
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QUEEN
AMAZONE: |
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QTY.
BUNCHES: |
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ROSSINI: |
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QTY.
BUNCHES: |
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SAHARA: |
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QTY.
BUNCHES: |
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SOURTINE: |
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QTY. BUNCHES: |
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STAR AMBIANCE: |
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QTY. BUNCHES: |
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TOBASCO: |
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QTY.
BUNCHES: |
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VERDI: |
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QTY.
BUNCHES: |
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WILD ONE: |
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QTY.
BUNCHES: |
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COMMENTS |
DELIVERY
DATE |
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| PAYMENT
INFORMATION (DELIVERY AND FLORIDA TAXES CHARGES APPLIED) |
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Credit
card |
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Card
Number |
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Credit Card
Secure Code |
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(3 Numbers - see back of your Card) |
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Cardholder
Name |
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Cardholder
Billing Address |
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Complete of Zip Code |
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Expiration
Date |
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(MM/YY) |
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SPECIFY
ANOTHER
PAYMENT METHOD: |
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CASH
ON DELIVERY: |
MONEY
ORDER: |
CASH
CHECK: |
CASH
IN ADVANCE: |
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OTHER:
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PLEASE
SPECIFY |
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We
will contact you via e-mail or phone shortly with your order
confirmation |
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Please
verify your information carefully before submitting for
ordering |
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