2013 Singing Valentine Order Form

2013 Singing Valentine Order
Valentine Recipient Information
Name of Valentine Recipient

First NameLast Name
There are LIMITED opportunities for delivery still available. Please call Martha at 309-829-1533 to confirm availability before completing online reservation.
Date of Delivery
Requested Time
Provide a delivery window of at least 1 to 2 hours.
Delivery Location

Other
Delivery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Recipient Phone Number

Area CodePhone Number
Helpful Tips to find your Valentine at the delivery location.
Message for the Card
Person Placing Order

First NameLast Name
Phone # of Person Placing Order

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail address for Digital Picture
Secure E-mail for Confirmation
An e-mail that your Valentine does not use
Choice of Gift
How did you learn about Singing Valentines?
Learn about Singing Valentine Other:
Payment Details
Payment Method
Order Date

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

2013 Singing Valentine Order