Billing Information:
Name:
Address:
Suburb:
State:	Postcode:
Phone:
Email:
Payment:
	Select Payment Method Cheque Direct Deposit Money Order Please call me for my Credit Card Credit Card
Credit Card Payment
Card Name
Card Number
Card Exp Date
Signature: For printed orders
Comments/Special Instructions:
Please note we can now process Credit Card Payment, however we are not collecting them over the internet. If you would like to make a credit card payment for your order, please print a copy of this page and fax it to us with your card details or select "Call me for my Credit Card Details" from the payment menu. Post your order to: Flowers that Last 34 Clancy Street, Padstow Heights NSW, 2211