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| Date of delivery: | * |
| Surname, name of the customer: | * |
| Telephone number of the customer: | * |
| E-mail address of the customer: | * |
| Surname, name of the receiver: | * |
| Telephone number of the receiver: | * |
| The address of the receiver: | * |
| Structure of a bouquet, gift: | * |
| The text on a card (up to 10 words): | |
| Cost: | * |
| (* The fields designated by an asterisk, are obligatory
for filling) |
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