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(541) 928–2221


We Shop 4 U Order Form
Date

Today's Date

Order Time

Time of Order


Customer Information
Name

Please enter your name

Phone

Enter your contact number

Email

Enter your e-mail address


Store Information
Store

Enter the name of the store where you'd like us to shop (If you do not have a preference, then enter N ⁄ P)

Address

Enter the store address

City

Which city?


Shopping List Information

List the items and approximate cost of each

Total

Approximate total?


Drop Off Location Information
Address

Where do we deliver your order?

City

City?


Payment Information

We'll happily pay for your items as we pick them up providing you prepay for the items now by filling out the section below.
Name

Please enter cardholder name

Zip Code

Please enter zip code associated with the card

Please enter card number