FAX to: The White Rose Custom Floral Design

FAX # 1-541-924-0206

Please complete ALL information requested

Delivery Date_______________________

Deliver to: First Name____________Last Name_______________

Address_____________________Apt. or Space #_____________

City______________________Phone #______________________

Business if applicable_____________________________________

Item being delivered (include Teleflora # if chosen from web site)

______________________________________________________

Enclosure card message___________________________________

______________________________________________________

______________________________________________________

ALL INFORMATION IS CONFIDENTIAL AND NECESSARY ONLY FOR CREDIT CARD PROCESSING. NO PERSONAL INFORMATION WILL BE GIVEN OR SOLD TO THIRD PARTIES.

First Name_______________Last Name______________________

Mailing Address__________________________________________

City___________________State/Province__________Country______

Zip/Postal Code________Day Time Phone*(___)_________________

Type of credit/debit card (circle one) V-MC-DISC-AX-CB-DC

Card #__________________________________exp. date______

Customer Signature________________________________________

*We will call you with a confirmation of the order.