Grocery Delivery Form
Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
Beverages
Homemade Lemonade. A half gallon is $8.00.
Homemade Orange Juice. A half gallon is $8.00.
Milk in box. A half gallon is $4.00.
Milk in glass bottle. A half gallon is $6.00.
Beverages Calculation
Bread and Bakery
Olives, 20 oz, is $6.00.
Cheesecake is $16.00.
Brand A biscuits is $4.00.
Bread and Bakery Calculation
Breakfast and Cereal
Sliced bagels, 6 count, is $3.00.
Cereal Brand A is $3.50
Cereal Brand B is $3.50
Breakfast and Cereal Calculation
Canned Goods and Soups
Corned Beef is $4.50
Crushed pineapple is $5.00
Smoked salmon is $2.50
Ready-made soup A is $2.00
Ready-made soup B is $2.00
Canned Goods and Soups Calculation
Cookies, Snacks and Candy
Cookies is $4.00
Chocolate, Brand A, is $2.00
Chocolate, Brand B, is $2.00
Fruit Candies, Brand A, is $3.00
Fruit Candies, Brand B, is $3.00
Cookies, Snacks and Candy Calculation
Dairy, Eggs and Cheese
Dairy milk, 10 oz, is $2.00
Dairy milk, 50 oz, is $4.00
Eggs, 12 count, is $4.00
Eggs, 24 count, is $6.00
Cheese, Brand A, 8 oz, is $6.00
Cheese, Brand A, 20 oz, is $12.00
Dairy, Eggs and Cheese Calculation
Frozen Foods
Frozen small pizza is $6.00
Frozen medium pizza is $10.00
Frozen XL pizza is $17.00
Frozen yogurt is $3.00
Frozen fruit, apple, is $5.00
Frozen fruit, berry, is $5.00
Frozen Foods Calculation
Grains, Pasta and Sides
Pasta, Brand A, 12 oz is $5.00
Pasta, Brand A, 20 oz is $6.00
Pasta, Brand B, 12 oz is $5.00
Potato salad, 5 oz, is $3.00
Chicken salad, 15 oz, is $7.00
Grains, Pasta and Sides Calculation
Meat and Seafood
Skinless chicken breasts, 3 slices, is $10.00
Beef ribs, 5 slices, is $20.00
Meat and Seafood Calculation
Paper Products
6 rolls of toilet paper is $12.00
12 rolls of toilet paper is $20.00
6 rolls of towel paper is $15.00
12 rolls of towel paper is $25.00
Paper Products Calculation
Cleaning Supplies
Laundry Detergent for 24 washes is $12.00
Laundry Detergent for 50 washes is $20.00
100 ml dish-washing soap is $10.00
Cleaning Supplies Calculation
Health & Beauty and Personal Care
Brand A Shampoo is $10.00
Brand B Shampoo is $9.00
Brand A, 25 ml, toothpaste is $6.00
Brand B, 25 ml, toothpaste is $7.00
Brand A soap is $2.00
Brand B soap is $2.00
Health & Beauty and Personal Care Calculation
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Total Calculation
Preferred Delivery Date
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Notes
Total Amount to Pay
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( X )
USD
1
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