Your Name:_______________________________________________________________ Street Address:__________________________________________________________ City:_________________________________ State/Province:___________________ Country:______________________________ Postal Code/Zip:__________________ Your Customer I.D. No. (if you have one):________________________________ Method of Payment: Cheque [ ] Money Order [ ] Visa [ ] Mastercard[ ] Credit Card Number:___________________________________ Expiry Date: Mo:____ Yr:____ Signature:_______________________________ Total Price From Below:$_________________ Send my order for Gift Boxes as follows. Greeting instructions and remittance are enclosed: BOX No.:___________ Price:$____________ BOX No.:__________ Price:$__________ Name:__________________________________ Name:________________________________ Street:________________________________ Street:______________________________ Province/State:________________________ Province/State:______________________ Cntry.:_______________ Postal:_________ Cntry:_____________ Postal:__________ BOX No.:___________ Price:$____________ BOX No.:__________ Price:$__________ Name:__________________________________ Name:________________________________ Street:________________________________ Street:______________________________ Province/State:________________________ Province/State:______________________ Cntry.:_______________ Postal:_________ Cntry:_____________ Postal:__________ BOX No.:___________ Price:$____________ BOX No.:__________ Price:$__________ Name:__________________________________ Name:________________________________ Street:________________________________ Street:______________________________ Province/State:________________________ Province/State:______________________ Cntry.:_______________ Postal:_________ Cntry:_____________ Postal:__________ Mail to: Amblecote Estate, 6325 Lakes Road, RR#1, Duncan, B.C. Canada, V9L 5V6 |