Exotica Florist Order Form

Order Form
Please complete all sections of this order form. Balloons · Multiple Orders: To send this item to more than one recipient, or to order different items, first submit this order. Then select the Next Order link. · Underlined fields are required. Incomplete forms will not be processed. · Click here for more information about delivery policies and procedures.
Size of Item:	Qty:	Delivery Date: Day: Month: Year:

Gift Card Message	Due to size of florists' gift cards, this message box allows for no more than 120 characters.
Enter Message eg."Happy Birthday!"
Gift Card Signature: eg. "Love, Bob"

Billing Information

First Name

Last Name

Billing Address

City

State/Province

Country

Zip/Postal Code

Day Telephone

Ext

Evening Telephone

Fax

Credit Card		Credit Card Number
AMEX Visa MasterCard	Diners Club CarteBlanche Discover
		Expiration Month:	Expiration Year:

Delivery Information
Recipient First Name
Recipient Last Name
	Is recipient's address the same as the billing address? Check if yes.If not, please complete the Delivery Information below.
	We are unable to accept orders for Post Office Boxes or APO's.
Select One	Residence Business Funeral Home Hospital Other
Institution / Business Name
Address
City
State/Province
Zip/Postal Code
Country
Telephone	Ext Phone numbers are required for all rural route addresses

Delivery Instructions

Please specify any delivery instructions. Requests for delivery at specific times of the day can be requested but cannot be guaranteed.

Please Let Us Know...

How did you hear about Exotica Florist?

Any suggestions?

Please inform me via email of special promotions or discounts.

Discount Club
	I am registered with the Exotica Florist Discount Club. I get 10% off all flower and basket orders, and 15% off all orchid purchases!

Place Your Order

Please verify that all of the above information complete and accurate.

OR
Fax to: 619-338-4917.

OR
Print and mail to:
Exotica Florist, 1335 5th Avenue, San Diego, CA 92101.

OR
You may also order by telephone:
619-338-8130 in San Diego
1-800-471-8334 in the US and Canada.