The Flower Shop Brockville Online Order Form

ONLINE ORDER FORM

The Flower Shop Brockville
Your Name: *

First Name Last Name
Phone number: *
E-mail
example@example.com
Delivery Details:
Delivery Date *

Month Day Year
Date
Recipient *

First Name Last Name
Recipient's Phone Number *
Delivery Address *

Street Address

Street Address Line 2

City Province

Postal Code Country
Card Message *
Special Instructions
Your Flower Order

Designer's Choice

Standard

$ 55.00 CAD Color Container

Premium

$ 75.00 CAD Color Container

Deluxe

$ 95.00 CAD Color Container

Delivery Please indicate delivery area. Free delivery within town limits.

Free Delivery Fee
Item subtotal: $ 0.00 CAD

Subtotal

$ 0.00 CAD

Tax

$ 0.00 CAD

Total

$ 0.00 CAD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

click to accept terms *

Yes, I accept The Flower Shop order terms & conditions.
Should be Empty: