| Your Name (not disclosed to recipient) | |
| Street | |
| Unit # | |
| Town/City | |
| If Other please state | |
| Province | |
| Country | |
| Postal / Zip Code | |
| Victim's Name | |
| Victim's Street | |
| Victim's Unit # | |
| Victim's City/Town | |
| If Other please state | |
| Victim's Postal Code | |
| Victim's phone number (if known) | |
| International Orders Please type in full address including country and code/s. | |
| Date of Delivery d/m/y | |
| Time of Delivery (specify am or pm) | |
| Select Number of dozen | |
| # of Dozen | |
| Select Colour | |
| Would you like roseless stems? Petals will be scattered in box. | |
| Would you like the roses broken? | |
| Would you like the roses awfully scented? | |
| Type your message that you would like to send to your victim | |
| Would you like us to email you to confirm delivery? | |
| Method of Payment | |
| Card Number | |
| Card Expiry Date (mm/yy) | |
| Name of Card Holder | |
| I agree or disagree to the terms and conditions by typing my name into the box above. | |
| Date | |
| |
