Order Form

     Please provide the following ordering information:

QTY	CODE, DESCRIPTION , PRICE AND SIZE

If you have any concerns about credit card security please call 00 64 33252621, or fax 0064 33256135, or txt 0064 2163214 or email broadfieldflowers@xtra.co.nz ,with your credit card details.

	BILLING
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number
Expiration Date

     Please provide delivery information, for rural deliveries please include a rapid number:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
or Work Phone
or E-mail

          Enter the date of delivery:

-- dd/mm/yy

Message to be included with flowers or gift

   Please provide the following contact information for confirmation of the order or if there is difficulty with delivery:

First Name
Last Name
Home Phone
E-mail