Romantic Evenings Order Form

No longer active page Return to Cyberparent.com	Romantic Evenings
Gifts for the Special People in Your Life

If you are paying by check or money order--or--you are not comfortable leaving your credit card number on the web, use the following method for ordering:

1. Print out this file.
2. Fill in entire form.
3. Mail with check or money order as instructed below. If you are uncomfortable leaving your credit card number on the internet, this form can also be used for credit card orders.
4. Checks will be held for clearance.
5. Shipment times will vary with products ordered.
6. All payments in US Funds. Shipments only within US at this time.
7. Only one order per form, please, because of gift card and shipping information

Your name _______________________________________________________
Your address ______________________________________________________
________________________________________________________________
Your email: _____________________________________________________
Your telephone number: (______) _____________________________ We must have your phone number to process order. Your private information is never sold/shared in any manner.

**Romantic Evenings: Use separate form for each gift please**
*Description*	*Style*		*Price*	*$$$ Ordered*	*Shipping information: Please Print*
Three Months	10135		$ 86.00	$	*Recipient's Name:*
Six Months	10136		$ 163.00	$	*Recipient's Phone # ( )*
Twelve Months	10137		$ 316.00	$	*Address:* *City/State/Zip:*
*Texas residents add 8.25% for sales tax*				$
*Shipping: UPS Ground*		3 months: $12.00		$	This makes a wonderful anniversary or wedding gift. If you give this to another person. your gift card should read:
		6 months: $24.00
		12 months: $48.00
*Total due*				$

**Romantic Evenings: Use separate form for each gift please**
*Description*	*Style*		*Price*	*$$$ Ordered*	*Shipping information: Please Print*
Three Months	10135		$ 86.00	$	*Recipient's Name:*
Six Months	10136		$ 163.00	$	*Recipient's Phone # ( )*
Twelve Months	10137		$ 316.00	$	*Address:* *City/State/Zip:*
*Texas residents add 8.25% for sales tax*				$
*Shipping: UPS Ground*		3 months: $12.00		$	This makes a wonderful anniversary or wedding gift. If you give this to another person. your gift card should read:
		6 months: $24.00
		12 months: $48.00
*Total due*				$

**Romantic Evenings: Use separate form for each gift please**
*Description*	*Style*		*Price*	*$$$ Ordered*	*Shipping information: Please Print*
Three Months	10135		$ 86.00	$	*Recipient's Name:*
Six Months	10136		$ 163.00	$	*Recipient's Phone # ( )*
Twelve Months	10137		$ 316.00	$	*Address:* *City/State/Zip:*
*Texas residents add 8.25% for sales tax*				$
*Shipping: UPS Ground*		3 months: $12.00		$	This makes a wonderful anniversary or wedding gift. If you give this to another person. your gift card should read:
		6 months: $24.00
		12 months: $48.00
*Total due*				$

Payment by ___ Check No. ______________ payable to CyberParent. All payments in US funds.
Payment by ___ Money Order payable to CyberParent. All payments in US funds.
Payment by ___ Credit Card. Must fill in form below. All payments in US funds.

Mail order with payment to CyberParent. P O Box 610207, Dallas, TX 75261
Thank you for your order. First gift shipped within two weeks. Consecutive gifts shipped right after first of each month. If you order this gift for another person, we will mail a card from you to that person immediately.

I authorize CyberParent to charge my ___ MasterCard ___ Visa ___ American Express
Account number _____________________________ Amount: $_____________________.
Expires ______ / ______ / _______.

Please print:
Billing Name: __________________________________
Billing Address: ____________________________________________ Suite ____________
City, State, Zip: ____________________________________________________________

Note: The opinions expressed herein are exclusively those of the writers and do not necessarily reflect the position of CyberParent. They are not intended to take the place of advice of a health, legal, or other professional whose expertise you might need to seek.