Corporate Accounts

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Store Hours

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Directions

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Shipping & Delivery

Call us to place an order 631.476.1046	Send us an Email sales@dellaruba.net
Fax us your order Print out this form and fax it. 631.476.1039	Print out this form and mail it. 12 Chandler Square Port Jefferson New York, 11777

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Purchase Amount ________________ Tax Amount (NY Sate Residents) ________________ Total Due ________________

Credit Card Information

Name on Card: _____________________________________ Account Number: _____________________________________ Expiration Date: _____________________________________

Master Card Visa Discover American Express

Billing Address

Name: Email: __________________________________ __________________________________ Address: Phone: __________________________________ __________________________________ City: __________________________________ State: __________________________________ Zip: __________________________________

Shipping Address (Same as billing)

Send To: Phone: __________________________________ __________________________________ Address: Product: __________________________________ __________________________________ City: Gift Message: __________________________________ __________________________________ State: __________________________________ __________________________________ __________________________________ Zip: __________________________________ __________________________________ __________________________________

Shipping Address (Recipient B)

Send To: Phone: __________________________________ __________________________________ Address: Product: __________________________________ __________________________________ City: Gift Message: __________________________________ __________________________________ State: __________________________________ __________________________________ __________________________________ Zip: __________________________________ __________________________________ __________________________________

Shipping Address (Recipient C)

Send To: Phone: __________________________________ __________________________________ Address: Product: __________________________________ __________________________________ City: Gift Message: __________________________________ __________________________________ State: __________________________________ __________________________________ __________________________________ Zip: __________________________________ __________________________________ __________________________________