If you need help filling out this form or you would prefer to place your order over the phone call 1800 808 988

Print out this form & fax to 07 3256 3044

Flower Selection Name: .....................................		Flower Item Code: ...................................
		Found on the page before the order form:"Your Selection"

RECIPIENT INFORMATION

Desired Delivery Date:

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Same day delivery is possible in most areas if order is placed before 1 pm (EST) (Monday to Friday. Limited Deliveries Saturday.

Card Message:	........................................................................................................................................................
	........................................................................................................................................................

Note: 20 words or less. Please remember to include sender's name (e.g. Love, Ian).

WHO WILL BE RECEIVING THE GIFT?

Title: .....................................	First Name: ........................................................
Surname: .....................................................................................

Select One:	Residence	Business	Hospital	Funeral Home
	Other (specify)	..............................	..............................	..............................

Company (if applicable):	........................................................................................................................................
Address:	.......................................................................................................................................

City:	......................................................................	Country:	.......................................................................
Postcode:	......................................................................	Phone:	.......................................................................

Special Instructions:	(* Leave at No. 58 if not home. * Specify flower choice and colour. * Specify gourmet products.)
.....................................................	...............................................................................................................

SENDER INFORMATION

Title: .....................................	First Name: ........................................................
Surname: .....................................................................................

Address:

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City:	......................................................................	Country:	.......................................................................
Postcode:	......................................................................	Phone:	.......................................................................
Email:	.......................................................................	Fax:	.......................................................................

PAYMENT INFORMATION

Flower Value:	$.......................................................................
Delivery:	$.......................................................................
Total:	$.......................................................................

Credit Card Type:

Mastercard;

Visa;

Bankcard;

Amex;

Diners Club

Credit Card Number:

__ __ __ __  /

__ __ __ __  /

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Expiry Date:

__ __  /

__ __

Name on Card (Print):	.....................................................................................................................................
Signature:	.....................................................................................................................................

HOW DID YOU FIND FLOWERSHOP.COM.AU

TV;

Radio;

Search Engine;

Newspaper;

Other

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Suggestions / Comments:	.................................................................................................................................
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	.................................................................................................................................

Flowershop Australia, Enquiries: Ph 1800 808 988, or visit our website www.flowershop.com.au