Valentine’s Day Order Form
Order Details
Order Type
Delivery
Pickup
Delivery Date
-
Month
-
Day
Year
Date
Delivery Time
Hour Minutes
AM
PM
AM/PM Option
Pickup Date
-
Month
-
Day
Year
Date
Pickup Time
Hour Minutes
AM
PM
AM/PM Option
Recipient Details
Recipient Name
First Name
Last Name
Recipient Contact No.
Please enter a valid phone number.
Sender Details
Sender Name
First Name
Last Name
Sender Contact No.
Please enter a valid phone number.
Sender Email Address
example@example.com
Delivery Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Order Information
Select gifts below
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next
( X )
Single Rose
Single Red Rose
$
4.00
Quantity
1
2
3
4
5
6
7
8
9
10
1 Dozen Roses
12 pc of red roses
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Valentines Day Cake
Heart-shaped chocolate and vanilla cake
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
Chocolates
Heart-shaped chocolates
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Balloon Bouquet
Heart-shaped red balloons
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Method
Please Select
Credit Card
Check
Bank Transfer
PayPal
Card Message
Any additional instructions?
Submit
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