Flowers/Gift Basket Request

Flowers/Gift Basket Request

Please complete as many fields as possible. Submission will not be allowed until mandatory fields are completed.
Your Name (as the requestor of this order)*

First NameLast Name
Your Contact Number in case of questions:

000000-0000
Reason for order:*
Hospitalization refers to admittance for overnight stay, not for an ER visit or outpatient procedure.
Which Local Lodge Member is in the hospital?*

First NameLast Name
Which Local Loge Member has a hospitalized family member?*

First NameLast Name
How is the RECIPIENT of this order related to the Lodge Member?*
Only those listed are eligible to receive orders from IAM Local Lodge 463.
What is this family member's name?*

First NameLast Name
The deceased is related to which Local Lodge Member?*

First NameLast Name
How is the deceased related to this Local Lodge Member?*
Only those family members listed are eligible to receive an order from IAM Local Lodge 463.
Name of the deceased individual:*

First NameLast Name
This order will be delivered to:*
What would you like to send them?*
What type of arrangement would you like to send?*
A charitable donation of $125 can be made to a non-profit organization in lieu of flowers upon the death of a Member or a Member's immediate family. Checks will only be made payable to the N-P organization; under no circumstances to an individual. Checks will be mailed to the required mailing address of the N-P organization. If you, as the requestor, cannot provide the mailing address for donations to the N-P organziation, please abort this submission until that information can be obtained, or choose the flower/plant option.
Please provide the name of the Charity/Non-profit.
Please provide the MAILING ADDRESS of the Non-Profit Organization for the $75 charitable donation.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Send this sympathy arrangement to:*
Please provide the HOME address of the RECIPIENT for order delivery:

Name of Recipient

Street Address

CityState / Province

Postal / Zip Code
Please provide the Hospital Name and Room Number for the recipient of this order:*

Name of Hospital

Street Address (Including Room # )

CityState / Province

Postal / Zip Code
Please provide the Name of the Funeral Home and address for this delivery to be sent:*

Name of Funeral Home

Street Address (Including Room # if hospital)

CityState / Province

Postal / Zip Code
Please provide any notes or comments that would be helpful to the Good of the Order Committee when placing this order:
Date and Time of preferred delivery.

MonthDayYearHourMinutesAM/PM Option
Phone Number of RECIPIENT (in case of delivery problems)

000000-0000
Should be Empty: