fax order form

Please print the following form, complete it and fax it to us at 07 5503 0584 within Australia or 617 5503 0584 from overseas. Your order will be filled immediately upon receipt of your fax.

To order online, simply click on the pink buttons beside each image on our catalogue pages.

rosaflora@southport BACK TO ON LINE CATALOGUE Click on your Browser's 'PRINT' button. Complete the form and send by FAX. FAX TO: rosaflora@southport Gold Coast AUSTRALIA FAX Numbers: (07) 5503 0584 (from Australia) (617) 5503 0584 (from overseas) PHONE Numbers: (07) 5561 1776 (from Australia) (617) 5561 1776 (from overseas) FAX FROM Name: Street Address: Suburb: State: Country: Your Phone Number (with area code): Mobile: PLEASE SEND FLOWERS TO Name: Name of Business, Hospital, Location, etc: Level in Building, Unit Number, etc: Is this a Private Residence? YES / NO Street Address: Suburb: Recipient's Phone Number: Mobile Phone: Delivery Date: ORDER DETAILS: OCCASION: Description (please select from the catalogue) e.g., large mixed arrangement, 3 dozen red roses, etc. or CUSTOM JOB Style or Colour Price (including GST) e.g., $75.00 MESSAGE: CREDIT CARD DETAILS Card Type (please tick) Name on Card Card Number Expiry Date Bankcard VISA MasterCard Diners American Express