Funeral Flower Order Form
Customer Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Order Details
Name of the Deceased
First Name
Last Name
Card Message
Size
Regular Size
Premium Size
Other
My Products
prev
next
( X )
Flower A
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Color
Red
Blue
Green
Yellow
Magenta
Size
Regular Size
Premium Size
Other
Item subtotal:
$
0.00
Flower B
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Color
Red
Blue
Green
Yellow
Magenta
Flower C
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Color
Red
Blue
Green
Yellow
Magenta
Flower D
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Color
Red
Blue
Green
Yellow
Magenta
Flower E
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Color
Red
Blue
Green
Yellow
Magenta
Size
$
Free
Size
Regular
Premium
Other
Subtotal
$
0.00
Tax
$
0.00
Shipping
$
0.00
Total
$
0.00
Payment Method
Cash on Delivery
Credit Card
Purchase Order
Check
PayPal
Delivery Information
Delivery Date
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Funeral Home Name
Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requests or Special Instructions
Submit
Should be Empty: