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First Name:		Last Name:
Company Name:		Type of Business:
Web site:		(*) Email:
Address:		Zip Code:
City:		State:
(*) Work phone:		(*) Cellular:

Please, register my business in your Customer Database:
I would like to receive, by Email, Farms specials and Deals:

SELECT PREMIUM BICOLOR ROSES:
ALEX		Quantity
CARROUSEL		Quantity
CEZANNE		Quantity
CIRCUS		Quantity
KONFETTI		Quantity
LATIN LADY		Quantity
LIPSTICK		Quantity
NEW FASHION		Quantity
QUEEN AMAZON		Quantity
TANGO		Quantity
VERANO		Quantity

SELECT PREMIUM ORANGE ROSES:
CORAL SEA		Quantity
MARIANA		Quantity
MIRACLE		Quantity
ORANGE FRANCE		Quantity
SATURNO		Quantity
SOMBRERO		Quantity

SELECT PREMIUM PINK ROSES:
ANNA		Quantity
LIVIA		Quantity
MOUNA		Quantity
PECKOUBO		Quantity
VIVALDI		Quantity
BUGATTI		Quantity
ELIZA		Quantity
PURPLE CEZANNE		Quantity

SELECT PREMIUM SALMON ROSES:
ENSUENO		Quantity
MARLYSSE		Quantity
SAPHIR		Quantity

		COMMENTS OR SPECIAL INSTRUCTIONS:
DELIVERY DATE:


PAYMENT INFORMATION: Federal taxes Included - Delivery not Included

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Credit Card
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Credit card Secure Code		(3 Numbers - see back of your Card)
Cardholder Name
Cardholder Billing Address		Complete of Zip code
Expiration Date		(Format MM/YY)

We will contact you via e-mail or phone shortly with your order confirmation


	Carrera (strawberry red) Head size: large Opening speed: slow Vase Life: 14 -16 days	Black Magic (dark velvety red) Head size: large Opening speed: fast Vase Life: 10 -12 days	Classy (dark red) Head size: large Opening speed: slow Vase Life: 12 -14 days	Madame Delbard (pure red) Head size: large Opening speed: fast Vase Life: 10 -15 days