Vegetable Order Form

1
Name* This field is required.
First Name
Last Name
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2
Contact Phone Number* This field is required.
Contact Phone Number
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3
Email* This field is required.Required for email confirmation of order
example@example.com
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4
Date for Order* This field is required.
Date
Year
Month
Day
Date
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5
Current Time* This field is required.Please note, that any order placed after 2pm Wednesday WILL NOT be processed for delivery in the same week. You will need to place your order for the following week.
Hour
Minutes
PM
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6
Number of Packs Required* This field is required.
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7
Frequency of Order
"One Off"
Weekly
Fortnightly
Monthly
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8
Total Cost of Order in $ (NZD)
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9
Payment Information

Vegetable Bags are priced at $12.00 per bag

Payment can be made on collection via CASH or EFTPOS

Online banking is available -
Please make payments in advance to the below account

Pukete Neighbourhood House
BNZ Te Rapa
02-1272-0049021-00

Please use the below reference structure when making payment. This ensures we can effectively allocate incoming payments to your order!

Particulars: VEGETABLES
Code: DATE (Date of Order)
Reference: FIRST & LAST NAME
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10
Online Payment* This field is required.Please note this is for our record only, you will NOT be prompted to make payment now
YESNO
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11
Additional Notes for Order (Optional)
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12
Tags
[object Object]
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Should be Empty: