On-Line Order Form

I HATE YOU FLOWERS

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On-Line Order Form

To Place Your Order, please fill out form below.

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