Delivery Request Form
Contact 613 617 9671 or orders@veloz.ca for assistance
Client
Pickup Address
Delivery Address
*
Please include postal code.
Additional Instructions
Ex: Large box, buzzer#, delivery instructions etc.
Delivery Contact name
*
First Name
Last Name
Delivery Contact Phone#
*
Please enter a valid phone number.
Delivery Contact Email
*
example@example.com
Delivery Date
*
-
Month
-
Day
Year
Submit by 1pm for sameday delivery (mon-fri)
Member
*
Please Select
Jason
Paul
Johnny
Mo
POD
*
Status
*
Please Select
Completed
Cancelled
Pending
Take Photo
Total
hst not included
Submit
Hidden Current Time
Hour Minutes
AM
PM
AM/PM Option
Hidden Current Date
-
Month
-
Day
Year
Date
Should be Empty: