BCA Transfer Comfirmation Order Form

BCA Transfer payment is in Rupiah based on $1 = Rp 9.500. *rate may change without notice, please consult us before transferring*

Please do BCA transfer before filling out the form to:
Gemilang
BCA acct#: 082-300-2863

Your e-mail address:

Flower Type chosen: (example: Passion of Pink Roses Bouquet) separate by comma if order more than one

Your name:

Your phone number:

Receipt number from BCA:

Total amount paid: ** $1 = Rp 9500

Recipient Name:

Recipient Phone Number:

Delivery Date: yyyy/mm/dd
** required * Please give us at least 12 hrs to process your order
Next available delivery date: 2012/05/19

Recipient Address & Direction:

Notes for Recipient: