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Custom Gift Basket Order Form

* indicates required fields

*Your Name:

*Your Address:

*Your Phone Number:

*Credit Card Type & Number:

*Expiration Date:

*Recipeants Name:

*Recipeants Address:

*Recipeants Phone Number:

Occasion for Basket:

Basket Specifications (Any special requests):

*Price (Before Shipping or Delivery):

Message on Card:

Gift Basket Creator

Call 541-513-1781 Fax 541-683-1523

Write to P.O. Box 41031, Eugene, OR 97404

We Custom Build Gift Baskets Just The Way You Want Them!