CUSTOMER ORDER FORM
Tell us exactly what you need
CUSTOMER INFORMATION
Full Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Delivery Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rows
City / State / ZIP
Preferred Delivery Date
1
TIME SLOTS (Check your preferred delivery window)
Preferred Delivery Window
8:00 AM - 10:00 AM
10:00 AM - 12:00 PM
12:00 PM - 2:00 PM
2:00 PM - 4:00 PM
4:00 PM - 6:00 PM
YOUR GROCERY LIST
Include item, brand/preference, size, quantity, and special instructions when needed.
YOUR GROCERY LIST
Rows
ITEM
BRAND / PREFERENCE
SIZE
QTY
SPECIAL INSTRUCTIONS
1
2
3
4
5
6
7
8
SUBSTITUTIONS
Substitution Preferences
Choose closest comparable item
Contact me before substituting
Do not substitute
Budget is flexible
Other
ORDER DETAILS
Fresh handling • Careful shopping • Door-to-door service
FRESH & SPECIAL PREFERENCES
Produce preference:
Organic
Conventional
No preference
Produce / ripeness requests
Meat / seafood preferences
Refrigerated / frozen requests
GROCERY PUT-AWAY SERVICE
Grocery Put-Away Service Option
Yes - put my groceries away
No - delivery only
Where should items be placed? (optional)
DELIVERY PREFERENCES
Delivery Preferences Options
Text me when you're on the way
Text / call when you arrive
Leave at door if unavailable
Additional delivery instructions
CUSTOMER AUTHORIZATION
I authorize Black Glove Delivery to purchase the requested groceries on my behalf. If I selected substitutions, I authorize comparable substitutions within my stated limits.
I agree to the authorization above
Customer Signature / Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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