Send Flowers Nationwide - PRODUCT ORDER FORM

You Have Selected:

One Dozen Mylar Bouquet
(Bear Not Included)

                                                                                                         Product #:

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Please select the desired product price:
As Shown:                     $59.95        (designed without bear))

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Please select your mylar balloon theme:
    - Please choose one theme.
    - Balloon Bouquets will be designed according to your selected theme

          Baby Boy
          Baby Girl
          Birthday
          Get Well
          Love
          You're The Greatest / Congratulations / You're Special
          Best Wishes
          Thank You
          Everyday / Just For Fun / Thinking of You
          Kid Themes
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Custom Balloon Bouquets:
     *If you would like to send more than one balloon theme please list them in the text field below
           (example: a balloon bouquet where one may want to send different themes such as: love, best wishes, thinking of you)
1.
2.
3.
4.
5.
6.

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                                                                                              Step 1 -  Delivery Information:


                             Please Enter Delivery Date By Selecting Values in the Drop Down Menus - *Click on black down arrow for selections

                                                                                                     

_________________________________________________________________________________________________________________________________________                                                                                            Step                                                                                            Step 2 - Recipient Information:

 Recipient Name:

           *Please include apt number, hospital room number, or office suite number
     Recipient Address:     
                                        
                                        
                               *We are unable to deliver to p.o. boxes or rural route addresses                      
City:          State:           Zip:

Country:

Phone Number:   Area Code No.

Name of Apartment Building / Office Building / Hospital - *If applicable


Please enter any special instructions for delivery:





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Step 3 - Card Message Information:


Please Enter Card Message:
*Limited to 175 characters with signature



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Step 4 - Sender Information:


Sender Name:

*Please include apt number, hospital room number, or office suite number
     Sender Address:         
                                        
                                        
                                
City:          State:           Zip:

Country:

Phone Number:   Area Code No.

Email Address:

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Step 5 - Billing Information:


Please Select Credit Card Type:    Visa             Mastercard           American Express           Discover

Please Enter Credit Card Number:

Please Enter Expiration Date By Selecting Values in the Drop Down Menus - *Click on black down arrow for selections

Month:       Year:


Card Holder Name - *As it appears on card  

Credit Card Statement - Billing Address
                                                              
                                                             
City:        State:       Zip:

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Step 6 - Customer Survey:

How did you find us? - Please select from one of the following options below:

 Yahoo Looksmart Google ODP Alta Vista Hot Bot AOL
MSN Gigablast Excite Other Search Engine (Please enter name)

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Step 7 - Checkout:

( $8.50 for delivery and any applicable tax will be added to your order )


YOUR ORDER IS ALWAYS SAFE WITH Send Flowers Nationwide

All information entered will be encrypted and sent over Internet Industry Standard SSL - Secure Socket Layer
to ensure your safety and privacy

I am ready to submit my order to Send Flowers Nationwide:



Thank You For Your Order !


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