formmail.to/12roses

Phool Time : One Dozen Roses

You have the following payment options :
1. Pay by credit card
2. Mail your cheque / draft in favour of 'Bloom Florist' to
Bloom Florist Pvt. Ltd.
E-2, Krishi Vihar
Masjid Moth
New Delhi 110048

Orders will be despatched only after cheque/draft is cleared.
Allow 24 hours lead time for delivery

MasterCard and Visa credit cards ONLY.
American Express/Discover are NOT ACCEPTED.

Receiver's name
Receiver's address
Receiver's telephone number
Date of delivery
Message (upto 25 words)
Colour of roses	Red Yellow White Pink
Your name
How would you like to pay :
Cheque/Draft Number
Drawn on Bank
Dated
Amount (Rs.)	Please enter 300
Cardholder's name	Required if paying by credit card
Card Number	Required if paying by credit card
Expiration date / valid until	Please enter in MM-YY format
Which site did you come here from ?
Your e-mail address