Mrs. Flowers' Order form

Mrs. Flowers' Order Form
Mrs. Flowers Tel. 662-930-3196 Fax 662-513-2961(auto 24hr.)
or e-mail us at MrsFlowersInfo@yahoo.com

Item: C2 One pound fruit chocolates with a large mixed bouquet
Chocolate covered tropical delights--mangoes, pineapples, sunflower seeds, rasins and cashews--boxed and deliver with a bright colour bouquet of flowers

Price: $69

Customer e-mail :

(required)

Customer's Name :

Address1 :

Address2 :

City and Country :

Contact Work phone no :

(required)

Contact Night Phone No :

(required)

Deliver to:

Address1 :

Address2 :

City :

Zip Code :

Country :

Thailand

Home Phone :
(Bangkok's addresses are not systematic; we need the Tels to verify the location)

(required)

Work Telephone :

(required) Extension :

Delivery Date:

Time :

If your desired delivery time is not listed, please use a special requirement form to indicate your preference. We will try our best to accomodate your request.

SPECIAL!!!
Add your personal touch.Something special for him/her

Message :

Special Requirement:

Payment Method:

Credit Card Number:

For Master Card, please indicate the last three digit

Due to the new online regulation, Master Card has opted to require the last three digit of your credit card number. You can find them in the back of your card, printed on your signature panel.

Card Holder's name:

Valid Thru:

(required)

Mrs. Flowers 19 Phaholyothin 21 Rd. Ladyao Jatujak Bangkok Thailand 10900
Tel. 662.930-3196 Fax. 662-513-4456
E-mail:mrsflowersinfo@yahoo.com

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