DELIVERY DATE  _____________

                       

Recipient_____________________________________

           (First Name)                                                          (Last Name)

phone ___________________________________________________

            (Required for all out of Fremont, state or country orders)

 

Description  (describe what you would like sent)

 

 

 

Ô card message:  r happy birthday r get well r anniversary r plain

                                 r congratulations r thinking of you …

 message &

 signature             ___________________________________

                         ___________________________________

                           ________________________________________________________

                           ________________________________________________________

 

billing  Information

 

indicate amount not to exceed  $ ________.____*

 

r Mastercard

r Visa                                   Number ________________________________Exp_________

r American Express                                                                                                    mo / yr

r Discover

 

Name _________________________________________________________________

            (as it appears on your credit card)

Day time Phone: (    )________________________cell _____________________

 

Address   __________________________________________________

                    ______________________   ____________   ____________

                     (city)                                        (state)                    (zip)

 

r Mail my credit card receipt             r No receipt is necessary

 

r     Charge my OTTO & URBAN Account.

* please call 1800 944-2615 with any questions or pricing information