Date:

Delivery day & date:

Funeral Time (if applicable):

Recepient Address:

Recepient Tel No.:

Product Range & Code:

Card Message:

Other Requirements:

Customer Name:

Customer Address:

Customer Tel No.:

E-mail:

Confirm Order By:

Order Value:

Interflora Delivery Charge:

Extra Delivery(taxi, priority, etc.):

Total(all values include vat):