Your Information
Your Information
Your Name
Your email address
Your phone number
Your billing address
Please provide
complete address
including zip code.
Credit card type
Credit Card Number
Expiration
xpira
Recipient Information
Desired date of
delivery
Recipient's Name
Recipient's Phone
Number
(If business, please include
company name and suite
number.)
Delivery Address
Delivery Area
Message
Please include signature
Type of
arrangement
Upgrade Arrangement
Your total budget
including delivery
Additional Instructions
or Information
How did you hear
about us?
New orders require credit card owner verification or signed
payment authorization form.
Thank you for choosing Express Flowers.
Payment Information
Please input credit card information or leave blank, complete
order and call us to arrange payment
Format 555-555-5555
CVS Number
CVS number is a 4 digit number on the front of your AMEX
card and a 3 digit number on the signature panel on the
back of your VISA, MC and Discover card.
Format 555-555-5555
THIS IS NOT AN AUTOMATED
ORDERING PAGE.  PLEASE CALL US
TO CONFIRM YOUR ORDER AND
DISCUSS IN DETAIL YOUR FLORAL
ARRANGEMENT AND PRICING.  WE
CANNOT PROCESS YOUR ORDER
UNTIL WE SPEAK TO YOU.