Applegate’s Gift Baskets Order Form
It’s Easy…Fill out this form. Check off the boxes that apply.
Fax to: 1-780-413-6365

Today’s Date: __________ Your Name: _____________________________

(Provide a phone number where we can reach you.)

Phone #: Country Code (___) Area (____) Phone ______________________

Company Name (if applicable): ______________________________________________________________
(We will call you upon receipt of this order form)

AUTHORIZATION FOR ONE-TIME USE OF CREDIT CARD (Please print legibly)

Name: ____________________________________________

Address: _________________________________________

City & (Province/State/Country) __________________________________________________

P/C or ZIP Code _____________

Credit Card #: _________________________________________________

Expiry Date: ___________ Security Code: _________ (last 3 digits on the back of M/C or Visa OR the 4 digits on the right hand front of Diners or Amex card.

Exact name (as it appears on this card): ______________________________________________________________________

Address to which this monthly card statement is mailed:_____________________________________________________________________

__________________________________________________________________________

_____________________________________________________ P/C or ZIP_____________

Signature: __________________________________________

Budget

q $___ X ___

q $100 X ___

q $125 X ___

q $150 X ___

q $200 X ___

q $250 X ___

q $350 X ___

q $500 X ___

q $___ X ___

OR

q Name(s) of
Basket Chosen

_______________

q $______ Value

Food Types
(Check all that apply)

q Designer’s Choice

q Mix of Ready to Eat

q Coffee

q Tea

q Chocolate

q Premium Chocolate

q Sparkling Cider/Hot Cider

q Cookies/Sweets

q Antipasto/Cheeses/Crackers

q Smoked Salmon/Fish Pate

q Olives/Mushrooms

q Pasta/Seasonings

q Jam/Jelly/Biscuits

q Nuts/Crunchy Foods

q Sweets for Child

q Heart Smart

q Sugar Free

q Pasta and Sauces

Liquor/Wine

q White Wine

q Red Wine

q Sparkling Wine

q Champagne

q Kahlua

q Irish Cream

q Other__________

q Scotch

q Rum

q Vodka

q Beer

q Brand__________

Specifics of choice: ___________________

_____________________________________

Recipient (s) q Office (Under 10) q Office (10-20) q Office (20-50) q Office (50+) q Couple q Family/children q Single Woman q Single Man	Giftware q Bath/Beauty Products q Glassware/Mugs/Cups q Ornaments q Toys q Baby Goods q Men’s Ware q Candles/Holders q Other __________	Special Needs or Other Comments: __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
Basket Styles q No Preference q Quality Wicker q Economy Wicker q Economy Tray q Deluxe Trunk, Chest, etc q Cookie Box Base q Designer’s Choice	Décor Style q Christmas q Hanukkah q Usual Holiday Colors q Company Colors (please define) ________ ____________________ ____________________ q Designer’s Choice	Message for basket: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

Delivery

q Edmonton/St.Albert

q Rural Edmonton

q Calgary/Red Deer

q Other area Alberta

q Another Province

q _______________

q Will Pick Up

Date Needed By?

q ASAP

q Next 2 days

q Next week

q Near to Christmas

q Specific Date ______________

q Specific Time (4-hour window please)______________________

_________________________

Please attach
additional sheet if
there is too much info
to be included here.

Names: Recipient (s)?

_______________________________

Address of Recipient?

______________________________

_______________________________

Phone #s - Recipient?

_______________________(h)

_______________________(w)

_______________________(c)

Thank you for shopping with Applegate’s Gift Baskets.
We will call to confirm your order as quickly as possible.

For more ideas, shop our web site
www.applegatesgifbasket.com

Applegate's Gift Baskets
11838-160 Street
Edmonton, Alberta, Canada T5V 1C9
1-(780) 413-6362

Applegate’s Gift Baskets Order Form It’s Easy…Fill out this form. Check off the boxes that apply. Fax to: 1-780-413-6365

Applegate’s Gift Baskets Order Form
It’s Easy…Fill out this form. Check off the boxes that apply.
Fax to: 1-780-413-6365