Valentine’s Order Form

Name of Person Placing Order *

First Name

Last Name

Phone *

(###)

###

####

What Signature Design do you want to order? *

Love in Full Bloom - 12 Roses

Love in Full Bloom - 18 Roses

Love in Full Bloom - 24 Roses

Sweetheart Bouquet

Pretty in Pink - 12 Roses

Pretty in Pink - 18 Roses

Pretty in Pink - 24 Roses

Other

Choose Details *

Color of Rose - Red

Color of Rose - White

Color of Rose - Pink

Color of Vase - Clear (included)

Color of Vase - Red (additional $10)

Delivery or Pick-Up? *

Pick-Up address: 239 Woodlake Drive

Delivery (additional fee if outside Georgetown)

Pick-Up

Date of Delivery or Pick-Up *

MM

DD

YYYY

Time of Delivery or Pick-Up *

Hour

Minute

Second

AM PM

Name of Recipient *

First Name

Last Name

Phone Number of Recipient

(###)

###

####

Address of Delivery *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country