WeDeliverGroceries Order Form

Recipient's Full Name *

First Name Last Name

Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Recipient's email

Destination Phone Number *

Area Code Phone Number

Originator's Full Name *

First Name Last Name

Billing Address (if different than shipping address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Originator's email *

Originator's Phone Number *

Area Code Phone Number

Type of Order *

Ordering Delivery to Myself Ordering for Another Person (leave receipt with delivery) Ordering as a Gift (do not leave receipt, scan & email to orignator) Business Delivery

Requested Date and Time *

Month Day Year Hour Minutes AM/PM Option

Payment Options *

Cash Check Credit Card (4% processing fee) Gift Certificate Prepaid Account

Number of Returning WDG Bags

Charitable Donation

Add Donation Amount to Invoice Total Donate Recycle Bags Value Thanks, but no Donation at this time

Donation Amount

First Store *

Enter Items *

Second Store

Enter Items

Third Store

Enter Items

Special Instructions

Promo Code

Enter the message as it's shown *