Custom Chocolates Order Form

SAMPLE - Custom Chocolates Order Form Please fill out this form completely!

All Fields Required *
- Orders will be confirmed either by Email OR Phone. -
"Ship To" is Same as Order Info, Unless Specified in Comment Box

Ordering / Ship To - Info
       *   First Name:        *   Last Name:

           *   Address:     *   City:

           *  State:       *   Zip Code:   *   Phone Number:

                 *   E-Mail Address:

SAMPLE ORDER FORM
Available in LIGHT and DARK SUGAR-FREE Chocolate
( POUND-BOX Size ONLY ) ~ Use Check Buttons Below ~

                    Quantity   .           .   1/4 (One-Quarter) LB. Box       $6.00  each

                    Quantity    2           .   1/2 (One-Half) LB. Box       $10.00  each

                   Quantity    4           .   1(One) LB. Box          $18.00  each

        *     .  MILK Chocolate Assortment Box        .  DARK Chocolate Assortment Box
                                                   .  Mixed Milk & Dark Assortment Box
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
     .  Light Sugar-Free Add $5.00 / LB.         .  Dark Sugar-Free Add $5.00 / LB. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~                               .   Custom Order - (Fill In Comment Box Below)

Special Instructions
           Payments Accepted Only in Advance AFTER Order Confirmation :
                  by   Cashier's Check     or     Money Order

        *   Chocolates For Your Order: (Comment Box)             (see Chocolates Catalog)
        - Orders will be confirmed either by Email OR Phone.

                 SAMPLE ORDER FORM
After clicking SUBMIT, Order is sent to your Email "OUTBOX".
Check your Email, so that it may be Forwarded!
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