Vann Jernigan Florist   

                                                                 

                                  Fax order form   Fax: 404.892.2620

1529-C Piedmont Ave. NE  Atlanta, Georgia  30324       Tele: 404.881.9790
Sender Name ___________________________________________________

Senders Billing Address ___________________________________________

______________________________________________________________

City________________________ State_________ Zip __________________

Customer Phone ______________________ Ordered by _______________

Payment method [V] [MC] [AE] [DC]

Card Number_____________________________________ Exp. Date_______
CVV (3 Digit Security Code on the Back) ____________
Signature for Card Holder__________________________________________

 

Delivery Date....................... [M] [T] [W] [T] [F] [S]   Time [AM] [PM]

             Orders placed after 12noon cannot be guaranteed same day delivery.

                Quan.                                 Description                             Amount

 

 

 

 

Delivery Charge.............................................................         $                 15.00

Sales Tax 8%                                                                           $__________.00

Total                                                                                         $__________.00

Card Message ___________________________________________________

______________________________________________________________

______________________________________________________________

Deliver to ______________________________________________________

Address________________________________________________________

City_________________ State___________ Zip______________________

Phone_________________________

 

Thank You for Your Order!