Delice Corporate Order Form

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			............................................... Company Information ________________________________________ applicant’s name ________________________________________ applicant’s type of entity ________________________________________ ________________________________________ ________________________________________ address ______________ suite/floor ________________________________________ state city zip ______________ phone # ______________ fax # ________________________________________ e-mail ________________________________________ contact, title Billing Address (if different) ________________________________________ ________________________________________ ________________________________________ address ______________ suite/floor ________________________________________ state city zip Credit Card (circle one) VISA MC Amex Discover ________________________________________ account # ______________ expiration date Authorized Signatories __________________________________________________ __________________________________________________ Trade Reference ________________________________________ 1. company name ______________ phone # ________________________________________ contact ________________________________________ 2. company name ______________ phone # ________________________________________ contact Banking Information ________________________________________ bank name ________________________________________ name on account ________________________________________ account # ________________________________________ ________________________________________ ________________________________________ bank address ________________________________________ bank contact ______________ Date ________________________________________ Signature ________________________________________ Name ________________________________________ Title ________________________________________ Account Number

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ordering			Last edited on 05/05/2005 ©2004 Délice European Bakery & Café Designed by Winged Pea, 2004