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Image	Product Name	Qty	Unit Price	Total

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Your First Name *

Your Last Name *

Requested Delivery Date *

Recipient Name *

Recipient Phone *

Recipient Address *

Recipient City *

Recipient Zip *

Message To Recipient

Tag Line (e.g. Love, Henry)

Special Instructions

Sub-Total :	$0.00
Delivery :	$15.00
Tax :	$0.00
Total :	$15.00

I have read, understand, and agree to these Policy Statements. Also, I understand and agree that this arrangement will be made as similar as possible to the example but may vary due to seasonal availability of flowers.

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