Cookies by Diane Handmade Gourmet Cookies

Sender/ Bill To

Today's Date:

E-mail:

Name:

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Department:

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Suite/ Floor No.:

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Evening Phone:

How did you hear about us?

Credit Card Information

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Credit Card Number:

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Ship to - If Different From Sender/ Bill To Address

Name:

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Suite/ Floor No.:

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Please note: UPS will not deliver to a PO Box

Gift Information

Approx Delivery Date:

Gift Name	No. of Cookies	Qty.	Price Ea.	Name of Graphic Design (All Occasion Only)	Additional Price for Graphic Design	Total Price

Gift Message:

Name (for confirmation):

Order Total:

Appropriate shipping, handling and delivery charges will be added. Please give us a call if you have any questions. Thank you!