Groceries To-Go! Order Form

Grocery Delivery Order Form 216-630-2099
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Preferred Delivery Date*

MonthDayYear
Preferred Delivery Time*

:HourMinutesAM/PM Option
Delivery Options*
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Delivery Phone (if different than above)

Area CodePhone Number
Which local supermarket would you like us to use?*
YOUR GROCERY LIST

Look in your pantry, cupboards and refrigerator for items that you need to order. Use those products as a reference for the product information that we need to provide you with the best service. Before you throw away empty containers and boxes, make sure to write down all required product information: QUANTITY, SIZE, BRAND NAME and PRODUCT DESCRIPTION
PRODUCE
Fruits and Vegetables
DELI
BAKERY
Bread, Rolls, Tortillas, Bagels, Donuts, etc.
MEAT & SEAFOOD
DAIRY
Cheese, Eggs, Milk, Yogurt, Butter, etc.
BEVERAGES
Coffee, Tea, Juice, Pop, etc.
CANNED & JARRED GOODS
Vegetables, Spaghetti Sauce, Ketchup, etc.
DRY & BAKING GOODS
Cereals, Flour, Sugar, Pasta, Mixes, etc.
FROZEN
PAPER GOODS
Paper Towel, Toilet Paper, Aluminum Foil, Sandwich Bags, etc.
PET & BABY GOODS
PERSONAL CARE
Shampoo, Soap, Shaving Cream, etc.
CLEANERS & OTHER HOUSEHOLD GOODS
All Purpose Cleaners, Laundry Detergent, Dishwashing Detergent, Batteries, etc.
PHARMACY
ALCOHOL & TOBACCO
Wine, Beer, Liquor, Cigarettes, etc.
Substitute out-of-stock items with comparable items?*

YesNo
Special Instructions or Comments
Payment Options*

CashCredit CardDebit Card
Will card be present at time of delivery? (if using credit or debit)

YesNo
Are you a New Customer?*

YesNo
Your preferred way of contact *

PhoneE-mail
Promo Code
Signature*

Use mouse to sign your signature.
Should be Empty:

Grocery Delivery Order Form 216-630-2099