Food Delivery Order Form

Delivery Address

Address where Food is to be delivered
Name*

First NameLast Name
Address*

Street Address

Suite / Apt #

CityState / Province

Postal / Zip Code
Phone Number (MUST BE A CELL PHONE)*
Please enter a valid phone number.
Email*
example@example.com
Restaurant - PICKUP LOCATION

Please verify the address is correct for pickup location
Name of Restaurant (PICKUP)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Order Details:
Order Number or Reference Number for order*
Order Date*

MonthDayYear
Order Pickup Time (Time Order Will Be Ready)

AM/PM Option
Delivery Date*

MonthDayYear
Special Instructions (Provide any instructions here such as gate entry codes or other special instructions)*
Signature*

Powered by Jotform SignClear
Date Signed

MonthDayYear
NOTE: We will calculate the exact distance and send a secure payment link via text message. Once payment is received we will pickup your order and deliver to your address submitted with this form.

Current Delivery Rates:

NOTE: The first 3 miles is just $5.00. Each additional mile beyond the first 3 will be charged according to the chart below. For example, a delivery distance of 3.1 miles will be charged at the 4-mile rate of $6.00. And you are only charged from the restaurant to your location or delivery point.

3 miles = $5.00	7 miles = $9.00
4 miles = $6.00	8 miles = $10.00
5 miles = $7.00	9 miles = $11.00
6 miles = $8.00	10 miles = $12.00

Should be Empty:

Delivery Address

Restaurant - PICKUP LOCATION

Order Details:

NOTE: We will calculate the exact distance and send a secure payment link via text message. Once payment is received we will pickup your order and deliver to your address submitted with this form.